Evaluation of the Statement of Fitness for Work: qualitative … · 2013. 7. 16. · They include the 98 anonymous employers across 54 organisations and the 87 . employees across

Research report

Evaluation of the Statement of Fitness for Work: qualitative research with employers and employees by Mumtaz Lalani, Pamela Meadows, Hilary Metcalf and Heather Rolfe

Department for Work and Pensions

Research Report No 797

Evaluation of the Statement of Fitness for Work: qualitative research with employers and employeesMumtaz Lalani, Pamela Meadows, Hilary Metcalf and Heather Rolfe

A report of research carried out by the National Institute of Economic and Social Research on behalf of the Department for Work and Pensions

© Crown copyright 2012.

You may re-use this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit http://www.nationalarchives.gov.uk/doc/open-government-licence/ or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected].

This document/publication is also available on our website at: http://research.dwp.gov.uk/asd/asd5/rrs-index.asp

Any enquiries regarding this document/publication should be sent to us at: Central Analysis Division, Department for Work and Pensions, Upper Ground Floor, Steel City House, West Street, Sheffield, S1 2GQ

First published 2012.

ISBN 978 1 908523 59 4

Views expressed in this report are not necessarily those of the Department for Work and Pensions or any other Government Department.

iiiContents

ContentsAcknowledgements ................................................................................................................................. vi

The Authors ............................................................................................................................................... vii

Glossary of terms .................................................................................................................................... viii

Summary ....................................................................................................................................................1

1 Introduction .........................................................................................................................................7

1.1 Background ...............................................................................................................................7

1.2 Aims of the study ...................................................................................................................7

1.3 Method .......................................................................................................................................8

2 Approaches to managing sickness absence ............................................................................. 11

2.1 Organisational experience of sickness absence ............................................................ 12

2.2 Approaches ............................................................................................................................ 12

2.3 Policies, including occupational sick pay ......................................................................... 14

2.4 The role of occupational health ........................................................................................ 14

2.5 Procedures .............................................................................................................................. 15

2.6 Assistance, support and flexibility ................................................................................... 16

2.7 General absence monitoring and data analysis ............................................................ 16

2.8 Conclusions on approaches ............................................................................................... 16

3 Preparation for the fit note ............................................................................................................. 17

3.1 Awareness of the fit note prior to April 2010 ................................................................. 17

3.2 Expectations of the fit note ................................................................................................ 17

3.3 Preparatory action and early changes to absence management systems ........................................................................................................ 18

3.4 Guidance published by the DWP on the fit note ........................................................... 19

4 Employees’ discussions with GPs about fitness for work ......................................................... 20

4.1 Procedure of discussion with GP ........................................................................................ 21

4.1.1 Timingofdiscussions............................................................................................ 21

4.1.2 Whoraisedtheissueofreturningtowork....................................................... 21

iv Contents

4.2 Content of the discussion .................................................................................................. 22

4.3 Effect of discussion with GP ............................................................................................... 23

4.4 Assistance suggested ......................................................................................................... 24

4.5 Fit note content .................................................................................................................... 24

4.6 Employees’ views on doctors’ understanding of their health condition and advice .......................................................................................................... 25

5 Fit note content: employers’ experiences and views .............................................................. 27

Key points ........................................................................................................................................... 27

5.1 Extent of employers’ experience of the fit note ............................................................ 27

5.2 Fit note content: GPs’ use of the ‘may be fit for work’ option ..................................... 28

5.3 Practicalities of changes to work ...................................................................................... 29

5.4 Adequacy of information from GPs .................................................................................. 30

5.5 Other aspects of GPs’ use of the fit note ......................................................................... 32

5.6 Contact between employers and GPs .............................................................................. 33

5.7 What employers would like from GPs .............................................................................. 33

6 Discussion between employers and employees around fitness for work and adjustments .............................................................................................................. 35

6.1 Discussions about adjustments ........................................................................................ 35

6.2 Drivers of discussions about adjustments: the role of the fit note ............................ 37

7 Adjustments to enable return to work ....................................................................................... 39

7.1 Types of adjustments .......................................................................................................... 39

7.1.1 Alteredhoursandphasedreturns..................................................................... 39

7.1.2 Workplaceadaptationsandamendedduties.................................................. 40

7.2 The response of employees to adjustments .................................................................. 41

7.2.1Instanceswhereadjustmentswerenotpossible.................................................. 42

7.3 Financial and other implications of adjustments for employees and employers ................................................................................................. 44

7.3.1 Coststoemployers................................................................................................. 44

7.3.2 Coststoemployees................................................................................................ 45

7.4 The response of colleagues ................................................................................................ 45

7.5 Examples of adjustments ................................................................................................... 47

7.6 Whether adjustments had worked ................................................................................. 49

vContents

8 The fit note and an early return to work ..................................................................................... 51

8.1 The role of the fit note in assisting a return to work ..................................................... 51

8.2 Benefits of an earlier return to work ............................................................................... 52

8.2.1 Theeffectonworkofanearlierreturn.............................................................. 53

8.2.2 Theeffectsonhealthandwell-beingofanearlierreturn............................. 53

9 Employers’ views about the effect of the fit note ..................................................................... 55

9.1 Views on the effect of the fit note ................................................................................... 55

9.1.1 Employers’viewsontheeffectofthefitnoteonsicknessabsence........... 56

9.1.2 Viewsontheeffectofthefitnoteonthemanagementofsicknessabsence.................................................................................................... 59

9.1.3 Employers’viewsonotherimpactsofthefitnote......................................... 60

9.2 Suggestions for improvement to the fit note ................................................................. 61

9.2.1 ImprovementinGP/employerrelations............................................................ 61

9.2.2 Varyingviewsonthelevelofinformationthatshouldbeprovidedonthefitnote........................................................................................................ 61

9.2.3 TrainingonthefitnoteshouldbeprovidedtoGPs......................................... 61

9.2.4 Varyingviewsonthenumberoftickboxesonthefitnote........................... 61

9.2.5 AnoccupationalhealthadvisercouldactasahelpfulliaisonbetweenemployersandGPs............................................................................... 62

10 Discussion and conclusions ............................................................................................................ 63

10.1 The effect of the fit note ..................................................................................................... 63

10.2 Strengths and limitations of the research....................................................................... 64

10.3 Implications for policy and practice ................................................................................. 64

10.3.1 Fitnotepolicyandpractice................................................................................. 65

10.3.2 Employers’approaches,policiesandpracticesandthefitnote................. 67

Appendix A A sample copy of the fit note ....................................................................................... 69

Appendix B Method .............................................................................................................................. 70

vi Acknowledgements

Acknowledgements We would like to thank Bola Akinwale who managed the evaluation for the Department for Work and Pensions (DWP) for her guidance and support. We are also grateful to Amy Lee and Isobel Swarc who managed the evaluation in its early stages at the DWP.

This report draws on information, experiences and perspectives of many individuals, to whom we are very grateful. They include the 98 anonymous employers across 54 organisations and the 87 employees across these organisations. Our intention has been to faithfully present the information, experiences and views they gave to us. The interpretation of these has been our own responsibility.

We would also like to thank John Forth at the National Institute of Economic and Social Research (NIESR) who joined us in the fieldwork.

viiThe Authors

The AuthorsMumtaz Lalani is a Research Officer at NIESR. Her research focuses on disadvantage and discrimination in the labour market and migration. She has expertise in qualitative research methods.

Pamela Meadows is a Visiting Fellow at NIESR. Her main interests are first, the labour market and employment generally, and the experience of specific groups, including women, older people and those with employment disadvantages. Her second main area of interest is the economics of social policy.

Hilary Metcalf is a Senior Research Fellow at NIESR and director of employment research. Her main research interest is in disadvantage in the labour market and policies for addressing disadvantage. She is experienced in both qualitative and quantitative techniques, including survey design and policy evaluation.

Heather Rolfe is a Senior Research Fellow at NIESR. She specialises in qualitative research into labour market disadvantage, focusing on access to employment for young people and for disadvantaged groups. She has previously carried out research on mental health and employment and on the Fit for Work Service pilots.

viii Glossary of terms

Glossary of termsAdaptations and adjustments Changes which are made to the job or work environment to

enable a person to return to work after sickness absence.

Fit note Common name for the Statement of Fitness for Work.

Occupational Sick Pay (OSP) When an employee is on sickness absence, their employer may pay them above the Statutory Sick Pay minimum. This payment is known as Occupational Sick Pay.

Phased return Changes made to the job, work environment or hours to enable a person to return to work after sickness absence for a temporary period only. A return to normal working might be progressively introduced.

Sick note Prior to the Statement of Fitness for Work, the ‘sick note’ was the common name for the form provided by a doctor to patients to give to their employer (if required) when they were absent for seven days or more. The sick note stated that the patient was not fit for work. It did not include a ‘may be fit for work’ option or tick boxes for GPs to recommend adjustments.

The term is still commonly used to refer to the Statement of Fitness for Work.

Statutory Sick Pay (SSP) After three days’ sickness absence, most employees are entitled to a statutorily set minimum payment for each day’s absence (set in relation to pay and number of days normally worked per week). The maximum amount is £81.60 per week (January 2012).

For more details, see: http://www.direct.gov.uk/en/MoneyTaxAndBenefits/BenefitsTaxCreditsAndOtherSupport/Illorinjured/DG_10018786?CID=MTB&PLA=url_mon&CRE=sick_pay

Statement of Fitness for Work The Statement of Fitness for Work is the form provided by a doctor to patients to give to their employer (if required) when they are absent for seven days or more.

1Summary

Summary Main messages• The intent of the fit note was welcomed by many employers.

• Employers’ views about the effect of the fit note on sickness absence were varied. Some believed that the fit note had influenced sickness absence by focusing attention on return to work, leading to adjustments being considered and implemented more frequently. Others felt that the fit note had not changed their management of sickness absence and that discussions about adjustments did not involve the fit note.

• Detailed evidence on employers’ responses to fit notes that they received suggests that the fit note is likely to have reduced sickness absence and improved management of sickness absence, although this was not always recognised by them. The influence of the fit note is likely to be greater in organisations with less formal procedures and fewer resources at their disposal, many of which are smaller firms.

• Employees’ reports indicate variation in the content of fit note discussions with their GPs. Consultations did not always include discussion of the nature of the employee’s job and discussions about adjustments varied considerably in detail.

• Employers believed that GPs’ provision of practical fitness for work advice to patients can be hindered by GPs’ lack of detailed information about job roles and occupational health. Some suggested more direct contact between employers and GPs.

• Employers wanted to see more use made of the ‘may be fit for work’ classification and clearer and more complete information, for example, on the duration of sickness, nature of incapacity or recommended adjustments. However, employers’ views were mixed on the extent of detail that GPs should record on the fit note, for example on recommended adjustments.

• Employers reported making a range of adjustments in response to advice provided on the fit note and seemed to find adjusted hours the easiest change to make. However, some felt that the fit note could generate unrealistic employee expectations about possible adjustments.

• Some employees felt that the fit note had empowered them in return to work negotiations with their employer, and that their employer had become more willing to make adjustments.

• Some employees felt their health had been negatively affected by returning to work too soon. However, employers believed that GPs are inclined to follow their patients’ wishes and wanted GPs to use the ‘may be fit for work’ option more often.

• Our findings suggest that measures to increase the influence of the fit note on sickness absence durations could involve increasing GPs’ understanding of employers’ needs and the scope for workplace adjustments; provision of support to employers on potential adjustments; and improved direct communication between employers and GPs.

2 Summary

The studyThis study explores the experiences and outcomes of the fit note from the multiple perspectives of employers and employees to understand how these differ across businesses or organisations.

The study was based on qualitative research with a purposive sample of 54 employing organisations (selected to provide a spread across sectors, organisational size, industries and countries) all of whom had some experience of using the fit note. In each organisation, the person with an overview of sickness absence management was interviewed. If possible, employees who had had a fit note and line managers were also interviewed. A total of 58 human resource specialists, six occupational health specialists, 15 line managers, 11 other managers and 87 employees were interviewed. Fieldwork was conducted between March and July 2011.

The study was commissioned by the Department for Work and Pensions (DWP).

Sickness absence patterns and concernsIn the organisations in the study, nearly all sickness absence was for one or two days; most of the remainder was for less than a week. Longer-term absence was usually confined to a very small number of employees.

Short-term sickness absence (often of one or two days) was the main concern amongst the organisations in the study. However, in the public sector organisations there was also some focus on reducing long-term absence (over six or 12 months). In the private sector absences of this length were rare and the emphasis was on reducing unpredictable short-term absence.

The most common causes of sickness absence were minor complaints (such as colds, flu and minor stomach problems) and stress. For long-term sickness, the main causes reported were musculoskeletal (including due to fractures and in some cases, back problems and workplace injuries), mental health conditions, stress and cancer. Operations for musculoskeletal conditions and cancer were also causes of long-term sickness absence.

The conditions perceived by organisations as being most difficult to manage were those where the progress was uncertain, including stress, anxiety, depression and other mental health conditions, ME and undiagnosed conditions.

Approaches to managing sickness absence Organisations vary in the extent to which they proactively manage sickness absence. Some are entirely passive. Others intervene, both to manage costs and to improve employee well-being, or with an emphasis on capability and disciplinary action.

Some organisations kept in touch with employees on sickness absence and used return to work interviews. These organisations helped facilitate adjustments both prior and subsequent to introduction of the fit note.

In their management of sickness absence, some organisations use trigger points for automatic intervention, including attendance plans and formal warnings. Others monitor trigger points but allow discretion as to whether or not formal intervention is triggered.

Among organisations in the study there were differences in the payment of Occupational Sick Pay (OSP). In public sector organisations, six months on full pay followed by six months on half pay was the norm. In the private sector, some did not pay OSP and the standard payment period varied

3Summary

from ten days to a year. Some used rolling periods for payment, some set years. Payments could be subject to a qualifying period and the total period of absence for payment of OSP.

Good occupational health services can play a critical role in advising employers, liaising with healthcare professionals and providing assistance to employees. However, employer reports suggest that services vary in their quality and understanding of the requirements of individual businesses.

Preparation for the fit noteMost of the organisations that were interviewed in the study reported that they were aware of the fit note and what it entailed before it came into effect, although not all had been.

Expectations of the fit note varied: some organisations thought that GPs would place more emphasis on what individuals could do when they were sick even if this meant working at a reduced capacity. Others thought that the fit note would have little impact and GPs would continue to sign people off sick.

Some organisations took no preparation for the fit note. Among those organisations which did take preparations, most tended to advise managers and employees on the changes to the sickness absence certification system.

Organisations that had seen the DWP guidance on the fit note generally found it to be useful and informative.

Employees’ fit note discussion with their GPsSome of the employees interviewed in this study had discussions with their doctor about adjustments for returning to work, although this was not the case across the board.

Discussions about adjustments for returning to work usually took place towards the end of the individual’s sickness absence period. The topic of returning to work was raised by individuals, GPs and, in some cases, by both. Some individuals also received advice from other healthcare professionals, including occupational health, which prompted them to bring up the issue of return to work with their GP.

The content of discussions varied: some GPs asked their patients about their job and what it entailed. Others did not. Similarly, discussions about changes to an individual’s job to assist return varied considerably in detail. Some GPs simply suggested a course of action while others had a detailed discussion about the changes that would be most appropriate to the patient’s job.

In some cases, discussions with GPs were led by the changes suggested by other healthcare professionals. In these cases, GPs simply facilitated the changes that had already been discussed between the individual and their employer.

Discussions with their GP about returning to work in a reduced capacity had various impacts on employees. In some cases, it enabled them to return to work earlier than they otherwise would have done or helped them to raise the issue of returning to work in a reduced capacity with their employers. In a few cases, individuals believed that the adjustments suggested had delayed their recovery process.

4 Summary

Fit note content Employers in the study had received few fit notes stating that an employee ‘may be fit for work’. They felt that this would have been appropriate in more cases.

There was much criticism from employers of the quality of completed fit notes: that the information was often incomplete or inadequate, consisting only of ticked boxes and with no guidance on adjustments such as activities to avoid. In addition, employers sometimes felt that changes suggested on the form were inappropriate, irrelevant or impossible. Employers believed GPs lack information about job roles, work organisation and occupational health more generally, which made it difficult for them to assess fitness for work or suggest appropriate adjustments to assist return to work. However, employers varied in how detailed they wished suggested adjustments to be.

Employers believed the GP/patient relationship inclined GPs to follow employees’ wishes, in respect of whether the employee was classified as ‘may be fit for work’ or not and in the adjustments proposed. This was felt to place the employer at a disadvantage.

Despite dissatisfaction with the quality of advice provided on the fit note, some employers saw it as a positive step in encouraging discussions about work and possible adjustments to take place between GPs and patients, which could lead to an earlier return to work.

Discussion between the employer and employee around fitness for work and adjustmentsDiscussions with employees around the fit note typically involved line managers, sometimes human resources managers and, in larger organisations, occupational health advisers.

Negotiation of adjustments often took place on return to work rather than being planned in advance.

For some employers, discussions about adjustments were reported to take place independently of the fit note (and had taken place prior to its introduction). Where this was the case, employers thought the fit note had made little difference to their discussions. However, some employees felt that the fit note had empowered them in their negotiations over returning to work and that their employer had become more willing to make adjustments.

Adjustments to enable return to work Most adjustments made by employers to enable employees to return to work had cost implications. However, for employers these were highly variable and not often calculated. The main cost to employees of adjustments was the potential loss of pay resulting from altered hours, phased return, or other arrangement involving reduced hours. Organisations varied in whether they made such reductions.

Adjustments to hours were the most common adaptation in the organisations in the study and, for employers, were seen as the easiest to make. Other adjustments were to work equipment and alternative duties. Employees generally welcomed all types of adjustments.

While employers said that making adjustments was usually worthwhile, they were not always possible and employees could be disappointed. Particular problems were reported with finding amended duties.

Reduced hours, on a temporary basis, were seen as simple and effective, and as helping to prevent early relapse which might lead to further sickness absence.

5Summary

The most successful phased returns were carefully planned and managed.

There were mixed perceptions of how colleagues of employees on a phased return reacted. Some employees felt their colleagues were very supportive when adjustments were made to help their return to work. Others did not perceive support. Employers were concerned that adjustments sometimes raised issues of fairness between colleagues.

Impact of an early return to workFor employers, the benefits of an earlier return to work were lower costs of sickness absence (in terms of costs of cover and lost business) and better service for clients.

For some employees an earlier return meant avoiding loss of pay and disciplinary action. In addition, sick leave was seen by employees as bad for their job security and career prospects, especially in the current economic climate. Moreover, employees commonly referred to having been bored at home and missed being at work.

However, some employees felt their health had been negatively affected by returning to work too soon.

Employers’ views about the fit notePrior to its introduction, some, although not all, employers were positive about the fit note. Some employers retained or developed this positive view and believed the fit note had had a positive impact. Others felt it had had little or no impact, but often remained positive about the idea, if not the practice.

Some, but not all, believed it had had an impact on sickness absence, through leading to greater consideration of adjustments, increased flexibility over adjustments, more adjustments being made, employees thinking more about returning and relapse being less common.

Those who thought it had not had an impact on sickness absence thought this was the case because they had previously made adjustments, employees had always been keen to return to work quickly, the fit note either did not suggest adjustments or useful information or they were treated as a sick note by employees or line managers. These views did not always tally with the detailed descriptions of how fit notes had been used.

Some employers believed the fit note had improved how they managed sickness absence and that managers or employees were better informed on appropriate action. Others felt it had made managing sickness absence more difficult, because it proposed inappropriate adjustments or raised employees’ expectations about adjustments.

The fit note was believed by some employers to have altered employers’ and employees’ attitudes to sickness absence, and some employers believed that information flows with GPs had improved due to the fit note, although these views were not universally held.

The effect of the fit noteThe evidence suggests that the fit note is likely to have reduced sickness absence, by prompting action by employees, employers and doctors which has facilitated return to work. It was likely to have had more impact in smaller organisations; organisations where adjustments had not previously been made; organisations without previous formal employer/employee discussion procedures on sickness absence; and in those without occupational health or other specialist health resources.

6 Summary

It appeared to have:

• led to more adjustments to assist return;

• led to the introduction or improvement of sickness absence processes, particularly in formal discussions about return and adjustments;

• empowered some employees to seek adjustments;

• led to some employers believing (erroneously) they must follow the advice given on the fit note.

The main issues affecting its effectiveness were:

• the extent to which the ‘may be fit for work’ option was used: it may be possible to use it more often;

• employers’ perceived inadequacies in the fit note completion and information;

• lack of dialogue between GPs and employers.

In addition, the following employer practices may impair the fit note’s effectiveness:

• rigid application of sickness absence management systems which penalise more the number, rather than length of sickness absence: these discourage risking a quicker return;

• reduction in pay if during a phased return.

Actions to enhance the influence of the fit note Employers varied in the detail they sought from the fit note. This seemed to vary with employers’ specialist health resources. Those with greater specialist resources seemed to prefer more information on employees’ health conditions, wishing identification of adjustments to be left to them. Employers with fewer health resources were more keen on suggested adjustments. This suggests that doctors might pay particular attention to the clarity of their advice where patients lack access to occupational health provision. However, employers generally wanted an indication of the period before recovery and during which adjustments were advisable.

There appeared to be some issues with the design of the fit note, which led to confusion over meaning and, perhaps, fit notes not being completed fully. This suggests that a review of the form design and guidance about its completion would be beneficial, for example, to make explicit what time periods refer to.

Some employers could gain more benefit from the fit note. Some need information to better understand the role and status of the fit note (as advisory). Further guidance and advice on good practice on managing sickness absence in general, and how to make adjustments for specific health conditions, or in certain occupations, could enhance employers’ use of the fit note. Likewise, support to implement aids and adaptations and greater awareness of existing support through Access to Work might also help employers to use the fit note more effectively.

There may be some need to consider provision of greater protection for employees’ health to avoid returns to work that are unsuitably early or without appropriate adjustments.

A number of the issues raised in the study also suggest a need for improved dialogue between GPs and employers, and ways of encouraging this could be considered.

7Introduction

1 Introduction1.1 BackgroundThe Statement of Fitness for Work (fit note) was introduced on 6 April 2010, replacing the previous medical statement (more widely known as the sick note). The aim of the change was to enable people who were off sick to return to work as quickly as possible. Unlike the sick note, which treated people as either fit or not fit, the fit note recognises that fitness is more nuanced and that a person may be able to return to work and contribute before they have completely recovered from an illness, even if they are not able to do their normal job fully. The fit note was also introduced in recognition of the recuperative benefits of a return to work.

Like the sick note, the fit note allows the doctor to state that the person is not fit for work. However, it adds a second possibility, ‘may be fit for work’, and for the doctor to then ‘record details of the functional effects of their patient’s condition – so individuals and employers can consider simple changes to the work environment or job role or other steps to help the employee return to work earlier’1. The expectation was that the changes would assist employers to reduce sickness absence and to retain staff and would change attitudes about how work can help recovery from sickness.

Key to the success of the fit note are:

• appropriate classification on the fit note of employees on sickness absence between ‘not fit for work’ and ‘may be fit for work’. This requires the doctor to make judgments not only on the limitations resulting from the illness or condition, but also on the requirements of the patient’s job and the extent to which alternative tasks might be possible. Too narrow a perception of requirements and alternatives may lead to employees being classified as ‘not fit for work’ when, in fact, work may be feasible. Conversely, unrealistic expectations of adjustments, adaptations and working hours changes may lead to employees being classified as ‘fit for work’ inappropriately;

• the extent to which the information provided by doctors on those judged ‘may be fit for work’ assists the employer (and employee) to identify appropriate ways of working during recovery and gets the person back to work more quickly. This relies on the doctor being able to identify appropriate information on limitations to provide on the fit note and to present this information in a useful fashion. Again, this requires some knowledge of the patient’s job and the extent to which alternative tasks might be possible;

• employers’ and employees’ flexibility in making changes to speed the return to work.

The Department for Work and Pensions (DWP) set up a programme of research to evaluate the fit note. This study forms part of that programme and provides evidence on how the fit note is operating based on qualitative research with employers and employees. It sheds light on the key issues above.

1.2 Aims of the study The overall aim of the study was to explore the experiences and outcomes of the fit note from the perspectives of employers and employees, and to understand how these differ across businesses or organisations.

1 DWP website, downloaded 24 November 2011, http://www.dwp.gov.uk/health-work-and-well-being/our-work/statement-of-fitness-for-work-fit/

8 Introduction

The objectives were to explore:

• approaches to managing general sickness absence in the business/organisation, if and how they had changed since the introduction of the fit note;

• views on the discussion and advice given by GPs on fit notes in facilitating an earlier return to work from both employer and employee perspectives;

• experience of using the fit note, the nature of discussions on fitness for work and, any job role/workplace adjustments from both employer and employee perspectives;

• success factors, barriers, incentives and disincentives for employers and employees to change behaviour and achieve an earlier return to work and insights into how any issues might be addressed; and

• the influence of the fit note in facilitating an earlier return to work and reducing sickness absence.

1.3 MethodThe study was based on qualitative research with employees and employer representatives from 54 employing organisations.

The organisations were selected purposively to provide a spread across sectors, organisational size, industries and countries. The sample was weighted towards low wage sectors, as these tend to have higher sickness absence rates. Certain industries (social care, food processing, call centres and hospitals) were included, owing to particular interest from the DWP. Organisations needed to have had at least one fit note to participate.

Potential participant organisations in the private sector were identified using a commercial database and, in the public and third sectors, using internet searches.

The employment size and industry of the participating organisations is shown in Table 1.1. Twenty-four of the organisations were from the private sector, 19 from the public sector and 11 from the third sector.

In each organisation, the person with an overview of sickness absence management was interviewed. This was normally a human resource specialist. Where possible, line managers (whose staff had had a fit note), employees who had been issued with a fit note and occupational health specialists were also interviewed. In 35 organisations a single manager or specialist was interviewed (Table 1.2). In organisations where more than one manager or specialist was interviewed, 11 included at least one line manager or senior manager. Eighty-seven employees, from 26 of the 54 participating organisations were interviewed.

9Introduction

Table 1.1 Characteristics of participating organisations

Number of employees

Industry 1 to 50 51 to 250251 to 1,000

1,001 to 5,000 5,001+ Total

Manufacturing 2 1 3Food processing 1 2 3Other non-services 1 1 1 3Retail 2 2Hotel 1 1 2Entertainment and leisure 2 1 1 4Banking and insurance 1 1Professional and business services 2 1 2 1 6Charity 1 2 2 2 7Public administration 3 1 4 8Emergency services 1 2 1 4Health 1 1Education 2 1 1 4Social care 3 1 4Other services 1 1 2Total 6 16 15 10 7 54

Table 1.2 Participating organisations and individuals by job role of participants

Multiple employer representatives interviewed Total

Single employer representative

interviewed Specialists onlySpecialists and

ManagersNumber of organisations 35 8 11 54

Number of people interviewedEmployer representatives 35 46 17 98 Specialists Human resources 23 21 16 60 Occupational health 1 4 0 5 Health and safety 1 0 1 2 Managers Line managers 0 18 0 18 Senior managers1 10 3 0 13Employees 44 17 26 87

1 For example, Managing Director, General Manager.

The interviews sought information on sickness absence policies and practices, in general, as well as detailed information on the use of the fit note. The employee interviews also gathered information on how doctors issued the fit note.

10 Introduction

Fieldwork was conducted between March and July 2011. Interviews were conducted by the National Institute of Economic and Social Research (NIESR) employment researchers using semi-structured discussion guides. Interviews were recorded (with the agreement of the interviewee) or notes were taken by the researcher.

Recordings were transcribed. Where interviews were not recorded, a note was written up after the interview. Analysis was thematic and, as appropriate, drew evidence from all respondents (human resource and other specialists, managers and employees). The method is described in greater detail in Appendix B.

1.4 Report layout The results of this study are reported in Chapters 2 to 9. The first part of the results (Chapters 2 to 6) describes how the fit note was used by employers and employees. The last part of the report (Chapters 8 to 10) considers the influence of the fit note in expediting employees’ return to work:

• Chapter 2 describes the context within which the fit note is used and outlines the range of organisational approaches to managing sickness absence;

• Chapter 3 turns to the fit note directly, and describes employers’ measures to prepare for its introduction;

• Chapter 4 describes employees’ accounts of their discussions with doctors about the fit note and their views on the appropriateness of the advice they received;

• Chapter 5 describes employers’ experiences of receiving fit notes and views on the content of completed medical statements;

• Chapter 6 examines the role that the fit note played in discussions between employers and employees about fitness for work and workplace adjustments;

• Chapter 7 examines the nature of adjustments made in the workplace;

• Chapter 8 turns to the role of the fit note in bringing about an earlier return to work and the effectiveness of adjustments;

• Chapter 9 gives employers’ views on the effect of the fit note;

• Chapter 10 draws conclusions on the effects of the fit note, highlights specific issues with its use and makes suggestions for improvement.

11Approaches to managing sickness absence

2 Approaches to managing sickness absence

Key points• Organisations vary in the extent to which they proactively manage sickness absence. Some

are entirely passive. Others intervene, both to manage costs and disruption and to improve employee well-being. Some organisations use trigger points for automatic intervention, including attendance plans and formal warnings. Others monitor trigger points but allow discretion as to whether or not formal intervention is triggered

• Variation in employer practice was also found in relation to arrangements for employees reporting that they were off sick, keeping in touch during absence, referral to occupational health services and return to work interviews.

• Among organisations in the study there were differences in the payment of occupational sick pay (OSP). In the public sector, six months on full pay followed by six months on half pay was the norm. In the private sector, some did not pay any OSP and for those that did the standard payment period varied from ten days to one to three months (or as in one case a year). In the public sector efforts were being made to reduce long-term absence (over six or 12 months). In the private sector absences of this length were rare and the emphasis was on reducing unpredictable short-term absence.

• Employer reports suggest that occupational health services vary in their quality and understanding of the requirements of individual businesses.

Employers adopted a range of approaches to managing sickness absence. At one end of the spectrum they took a passive approach, accepting absence as inevitable and waiting for employees to return to work when their doctors said they were fit to do so. Others took a more active approach. This was more common among some of the larger employers and was generally not evident in smaller organisations.

Employers who sought to actively manage sickness absence tended to operate broadly in one of two ways: Some viewed sickness absence purely as a business issue: absence from work could be disruptive and cost money. These employers tended to invoke formal disciplinary or capability procedures at an early stage, or after a small number of absences. Other employers who sought to manage sickness absence argued that an interventionist approach both reduced the cost of absence to the employer and genuinely improves employee well-being.

This chapter describes some key features of the range of approaches. First, as context, the extent and nature of sickness absence in organisations is described. We then discuss the importance employers place on managing sickness absence. Section 2.2 looks at general approaches, Section 2.3 at absence policies, including sick pay, and Section 2.4 at the role of occupational health. The following two sections examine practice in detail: the procedures followed when an employee has sickness absence (Section 2.5), the assistance, support and flexibility for employees who are sick or recovering (Section 2.6). Section 2.7 then examines absence monitoring.


2.1 Organisational experience of sickness absenceData on sickness absence rates was sought from the organisations in the study. Some provided a figure for the organisation, some for broad occupational groups. Others gave qualitative information (e.g. ‘high’, ‘average’ or ‘low’). Some were unable to provide any indication. For organisations that gave figures, sickness absence rates ranged from just over one per cent to almost eleven per cent of working days per annum, with most being between two and four per cent2. Where data was given for specific occupations, some reported it being lower (and some very low) amongst office and professional staff and higher amongst manual staff, others reported lower rates for manual staff.

Short-term sickness absence (often of one or two days) was the main concern amongst the study organisations. In some cases the concern was with individuals (often a small percentage of the workforce) having multiple short-term sickness absence. Long-term sickness absence was of concern only to a few organisations in the public sector.

The most common causes of sickness absence reported by organisations in the study were minor complaints (e.g. minor viruses such as colds and flu, and minor stomach problems) and stress. For long-term sickness, the main causes reported were musculoskeletal (including due to fractures and in some cases, back problems and workplace injuries), mental health conditions, stress and cancer. Operations for musculoskeletal conditions and cancer were also causes of long-term sickness absence.

Some organisations identified stress, anxiety, depression and mental health conditions as most difficult types of health condition to manage. The main issue seemed to be around uncertainty, including sickness absence being intermittent and length of sickness absence uncertain, together with variability of performance when at work. Uncertainty was also a feature of some of the other conditions seen as more difficult to manage, such as ME and conditions that were undiagnosed. However, for some organisations, uncertainty surrounding stress and mental health conditions seemed to be exacerbated by a lack of general understanding of these conditions or a lack of knowledge about the specific condition an individual had, which created difficulties with knowing how best to manage the sickness absence and return to work.

2.2 ApproachesMost organisations had written policies setting out the procedures involved in the notification and management of sickness absence. A few smaller organisations had no written policy. However, it is worth noting that employers who were sufficiently interested to take part in a study of sickness absence would probably be more likely to be more actively engaged with the issue of managing sickness absence and better informed than employers generally.

Different organisations had differing priorities. In the public sector one of the main priorities was about limiting long-term absence, with some organisations wanting to reach the position where nobody had been off sick for more than 12 months. In the private sector, absences of this length were almost unknown (although a few organisations did have a few people in this position). In private sector organisations in the study OSP was typically available for less than a month, and almost never for more than six months.

In some of the organisations which did try to manage all kinds of absence, absence was, in theory, a capability issue. If someone was not at work, they were not fulfilling the terms of their employment contract. In practice, however, very few organisations had dismissed staff as a result of sickness

2 Employers may have varied in how absence was calculated. The details were not collected.


absence leading to poor performance. They generally preferred to try other approaches first. Some employers based their approach on the premise that managing sickness absence effectively leads to improved employee well-being, because it reduced their absence and they believed that not being at work was not good for individual employees.

Some of the organisations with an active approach based on promoting employee well-being paid their occupational health providers to help staff manage a range of health conditions. Occupational health providers might also offer general advice and support to all staff on health promotion issues such as healthy eating and exercise.

When asked what they regarded as long-term absence, organisations that took an active approach to managing absence most frequently mentioned a month as the point at which additional interventions were triggered. However, a small number regarded ten days or more as long-term absence. Organisations that took a more passive approach, and were not looking to intervene, did not usually have a definition of long-term absence, but interviewees suggested three months or six months of absence would be regarded as long term.

Many organisations in the study were using the Bradford scale3 to indicate where particular staff had an absence pattern that was a cause for concern. The Bradford scale is a scoring system based on the theory that short, frequent, and unplanned absences are more disruptive to employers than longer absences. The system works by attributing points to absences according to their length and frequency. Organisations using Bradford scores were more likely to use the scores as indicators to be monitored rather than as automatic triggers for intervention. Some managers argued that the Bradford weighting was not a sufficient indicator of the need for action. It was apparent from interviews with employees in organisations where this system was used, and from interviews with employers, that using Bradford scores alone could lead to organisations either being more passive or more active than was warranted in the individual case.

Some of the organisations taking an active approach to absence management had their own trigger points at which line managers were expected to intervene. These points were well documented in sickness absence policies and understood by staff. But they varied between organisations. This illustrates the differing views of what constitutes ‘excessive’ absence. Three absences in 12 months was probably the most frequently mentioned trigger point among organisations using this approach. But the alternative intervention point – the number of sickness days taken in a 12-month period – varied from seven to 28 among the organisations that used such a trigger point.

For organisations that used trigger points, typically, the first step was a formal interview with the line manager. This could serve to identify those who might need adjustments or occupational health intervention. But in some organisations the initial line manager interview led directly to a formal attendance plan, requiring a particular attendance target over a three-, six- or twelve-month period. In other organisations an attendance plan required further absence triggers. If the attendance plan was not adhered to then absent employees might face disciplinary action or action to assess whether they were able to do their job and, if not, dismissed.

A small number of organisations reported that they moved straight to issuing formal disciplinary warnings after three absences in a 12-month period, without the line manager interview and attendance plan processes used by others.

3 The Bradford scale was developed from research undertaken by the Bradford University School of Management in the 1980s. For more detail on the system see: http://www.simplypersonnel.co.uk/downloads/2010/Bradford%20Factor%20Overview.pdf


There were differences between organisations in the study with active approaches as to whether invoking disciplinary or capability procedures was standard practice or subject to discretion. Only a limited number of employers included in the study had taken disciplinary action beyond drawing up an attendance plan. A few reported having issued a formal warning to a small number of employees, because they had been away for a long time (although the view of a long time varied between a month and a year), were unlikely to return to work within the foreseeable future, or were suspected not to be genuinely ill. Among organisations which had the disciplinary route built into their procedures it was more common for either line managers or human resources to have discretion over whether or not to invoke formal proceedings. Among these employers it would be unusual to take action against an employee who had developed cancer, had surgery, or had an injury requiring several weeks or months off. In a small number of cases, managers had no discretion and disciplinary procedures were automatically applied to everyone who had reached the appropriate trigger point, irrespective of the nature of the illness or injury involved or the likelihood of a return to work.

2.3 Policies, including occupational sick paySome organisations in the study had a return to work interview policy. All staff who had been absent because of sickness were supposed to have an interview with their line manager on their return to work. This might apply after every absence, even a single day, or only for longer absences (four or five days for example).Typically, return to work interviews were informal, in that they were not recorded as formal action, but sometimes they were part of a formal process.

Organisations varied in their practices as regards keeping in touch with staff who were absent through sickness. In some cases the view was that staff were ill at home (or in hospital) and that any attempt to contact them would be inappropriate and intrusive. Others had practices that ensured that line managers kept in touch with absent staff, normally by telephone, but sometimes by visiting them at home, or meeting in a neutral place such as a café.

Among the organisations in the study there was marked variation in the extent to which employees had access to OSP. In some organisations employees were only entitled to Statutory Sick Pay (SSP)with no supplementation. At the other extreme in one organisation (in the voluntary sector) all employees were entitled to 12 months on full pay and in another (in the private sector) some had this entitlement.

In the public sector the norm was six months on full pay followed by six months on half pay. Usually this had a qualifying period (for example in any rolling four-year period).

Most of the schemes in private sector organisations in the study were markedly less generous. Ten days’ paid sick leave in any rolling 12-month period was reported by several employers. The more generous private sector schemes (and most voluntary sector schemes) typically provided somewhere between eight and 12 weeks’ pay after a qualifying period.

2.4 The role of occupational healthSome of the organisations that took part in the study had made use of occupational health services. Smaller organisations were less likely to have used occupational health services, and where they


had done so it was not usually under a contract but was a one-off consultation. Across the whole economy it is estimated that only 34 per cent of the workforce is covered by occupational health arrangements.4 Usually the arrangement was to have a contract with a specialist occupational health provider, with larger organisations having staff dedicated to them, sometimes working on site. Two organisations had in-house occupational health services.

A minimal approach to occupational health services was to involve them only in helping to design and develop adjustments to enable somebody to return to work or to offer a second opinion about the likely timescale for someone’s return to work. At the other end of the spectrum occupational health providers offered open access private GP services to all staff, either on site or nearby.

Human resources managers felt that the quality and value of occupational health services varied. Staff attitudes towards occupational health services varied. In organisations where they were rarely used, a referral to occupational health could be regarded as threatening possibly because it indicated that the employer was considering the employees’ capability for work. However, some employers reported that sometimes employees find it easier to talk to occupational health professionals about the adjustments they need than to their line managers.

Managers reported that good occupational health services were able to advise them how long someone with a particular condition might need to be absent, given the nature of their job. They also helped them to identify malingerers and individuals who were no longer fit for work. Having access to occupational health services for people who are not absent but are managing a health condition in the workplace was reported by some employers to be particularly useful. A few occupational health services provided counselling and physiotherapy, which had been able to prevent people with some conditions (for example back or hip problems) from having to take time off.

Organisations sometimes used occupational health services to communicate with GPs, although this was not always successful. There could be differences of view between occupational health services and GPs about someone’s fitness to do their normal job. In jobs requiring high levels of physical fitness GPs might say someone is fit for work, but the occupational health service tests would suggest that they were not fully fit for specific duties. Conversely, GPs might say someone was unfit for work, but the occupational health service would be able to secure adjustments. These issues were often difficult to resolve.

2.5 ProceduresIt was standard practice across most organisations in the study, even those with a passive approach to absence management, that someone who was sick had to ring their line manager and speak to them personally on the first day of absence. If the line manager was away the usual rule was that they had to ring the line manager’s own line manager. Usually emails or text messages were not accepted, and neither, except in an emergency, was a notification from anyone other than the staff member.

Organisations also generally stipulated a time limit for making the telephone call. This was typically half an hour to an hour before or after the employee’s scheduled start time.

Organisations varied in their contact requirements after the first day. Some organisations, with less

4 Reported in Hussey, L., Turner, S., Thorley, K., McNamee, R. and Agius, R. (2010). Comparison of work-related ill health reporting by occupational physicians and general practitioners, OccupationalMedicine, Vol. 60 (4) 294-300.


formal systems for managing sickness absence, had no particular contact requirements. They would expect a phone call on the first day and a fit note on the eighth day, but subsequent contact would be dependent on the doctor’s recommendations or the renewal of the fit note. Several organisations required daily contact for the first seven days, then weekly contact thereafter, and for long-term absence a personal visit once a month. Another approach was to require a telephone call on day three or four of any spell of absence, then day seven or eight.

2.6 Assistance, support and flexibility Almost every organisation in the study was willing to make adjustments to help employees return to work and had experience of doing so. These adjustments included the full range of options included on the fit note. Employers’ willingness, ability and capacity to make these adjustments is described in detail in Chapter 7 in the context of responses to the fit note. As we explain, the staff involved in decision-making over such matters varied between organisations and included general managers, human resource specialists and line managers.

2.7 General absence monitoring and data analysisSome of the smaller organisations in the study recorded absence on individual staff cards and did not collate or monitor absence levels. However, all the larger organisations, and most of the medium-sized ones, had computerised recording systems.

Organisations in both the public and private sectors which had computerised recording systems generally reported sickness absence monthly (or sometimes quarterly) to their boards, trustees, governors or senior managers. A common reporting pattern would be absence over the past month, quarter and year compared with the same month and quarter the previous year, and comparing the year to date with the preceding year to date.

In some organisations there was only upward reporting of absence, but in others information was also sent to team managers to show the performance of their own unit compared with other parts of the organisation as well as a comparison over time.

2.8 Conclusions on approaches Organisations that had recently introduced a more formal and active approach to the management of sickness absence believed that absence rates had fallen as a result. However, active management of sickness absence, particularly where occupational health services are involved at an early stage, could be resource intensive. Some employers which used automatic trigger points and treated all absence as a potential disciplinary issue acknowledged that this approach could be regarded as unfair, both by staff and by line managers. Nevertheless, it was straightforward and widely understood by employees. Others which took a more flexible approach saw this as better for morale and fairness.

Organisations which did not try to manage absence tended to be small, to be in a position to monitor staff individually and believe that sickness absence was not a problem for them. Their approach may well have been the most appropriate one for their circumstances.

The findings in relation to employers’ approaches to sickness absence therefore suggest that there is wide variation in employers’ practices. They also show that, for many employers, the fit note was introduced at a time in which they were considering their approaches to this human resource issue. A particular concern of some employers was to reduce short-term absence.

17Preparation for the fit note

3 Preparation for the fit noteKey points• Most of the organisations that were interviewed in this study were aware of the fit note and

what it entailed before it came into effect. However, not all had been.

• Expectations of the fit note varied: some organisations thought that GPs would place more emphasis on what individuals could do when they were sick even if this meant working at a reduced capacity; others thought that the fit note would have little impact and GPs would continue to sign people off sick.

• Some organisations made no preparation for the fit note. Among those organisations which did make preparations, most tended to advise managers and employees on the changes to the sickness absence certification system.

• Organisations that had seen the Department for Work and Pensions (DWP) guidance on the fit note generally found it to be useful and informative.

This chapter looks at the preparations taken by organisations prior to and following the introduction of the fit note in April 2010. In addition, it briefly examines organisations’ awareness of the changes to the sickness absence certification system prior to April 2010, their expectations of the fit note and their perceptions of the guidance published by the DWP on the fit note.

3.1 Awareness of the fit note prior to April 2010Nearly all the organisations interviewed for this study were aware of the fit note and what it entailed before it came into effect.

The ways in which organisations learnt about the changes in the sickness absence certification system varied. Some organisations received emails about it through human resources and professional networks. Such organisations varied considerably in size. Several of these organisations specifically mentioned learning about it through updates from the CIPD and from ACAS. Other organisations were made aware of the fit note by their legal or policy team or by their employment law firm. The former tended to be larger in size while the latter ranged in size. Some establishments that were part of larger organisations were made aware of the change by head office. Organisations that were unaware of the change only realised that the system had changed when they received their first fit note. One of these organisations was a small business that was part of a larger group of companies while the other was a medium-sized business.

3.2 Expectations of the fit noteThe fit note was introduced with the intention of getting people back into work as quickly as possible by focusing attention on what individuals who are off sick can do rather than what they cannot. However, discussions with employers revealed that their expectations of the fit note and of its impact varied significantly.

Of those organisations that indicated any particular expectation of the fit note, some anticipated that GPs would no longer simply sign individuals off for a particular period of time and would instead place more emphasis on what the individual could do, even if that meant working at a reduced capacity. Such organisations varied in size, industry and sector. For example, one organisation

18 Preparation for the fit note

commented:

‘...myownperceptionofitisthattheethosofitiswiththefocusonattendance,ratherthansomeonebeingoffforsixweeks,completelybeingoff,thattheGPthenhasmoreofanopportunityfordialoguebetweentheGPandtheorganisationandthatiftheymaynotbefittodotheircorejobbuttheycoulddoX,YandZifyoucouldaccommodateit.’

Some of the organisations with such positive expectations of the fit note went on to add that they had been disappointed by the response from GPs. The disappointment expressed was either related to the fact that they felt GPs were not using the fit note to its full potential and rarely seemed to use the ‘may be fit for work’ box and suggest adjustments or because they believed GPs did not seem sufficiently aware of how the fit notes were supposed to be completed. For example, one organisation commented,

‘Ithinkthey’reactuallymoreconfusedthanemployersIthinkintermsofcompletingthem...ImeanIdon’tthinkI’veeverreceivedafitnotethat’scompletedcorrectlybyaGP.’

Employers’ understandings of correct completion of the fit note are described in Chapter 4.

Other organisations had lower expectations of the fit note, either saying that they did not think it would make any difference and that GPs would still simply sign people off as ‘not fit for work’ or that they did not see it as a particularly big change in procedure. These organisations also varied in size, industry and sector and in some cases already had an occupational health service which regularly implemented changes, including phased returns to work, that enabled individuals to return to work sooner. One organisation, a police force, indicated that:

‘Thisisnobigchangeforthisforce,it’sjustacaseofnowaligningthatwithsomethingthatwealreadydoratherthananymassive...thisisjustsomethingwe’vedoneforyears.’

Similarly, a large private sector organisation that had received three fit notes containing suggestions for adjustments out of a total of 50-75 fit notes commented:

‘Iwasscepticalatthetimeandmyscepticismwasbeingsortofconfirmedbytheeffectivenessorirrelevanceactually,probablyevenmoreharshistheirrelevanceofthesystem.’

The employer went on to add that the adjustments suggested in these three fit notes were unhelpful, either because of the illegibility of the handwriting or because insufficient detail was provided about the type of adaptation required.

3.3 Preparatory action and early changes to absence management systems

Some of the organisations interviewed had made no preparation at all for the fit note. Such organisations were of all sizes, industries and sectors. Amongst those organisations which had taken actions to prepare for the introduction of the fit note, most indicated that this involved advising managers and employees of the changes to the sickness absence certification process. This was usually done electronically but occasionally also through face-to-face meetings. In some cases, interviewees indicated that they had also made slight amendments to their sickness absence policy although this tended to be simply replacing any mention of the ‘sick note’ with ‘fit note’.

Some of the human resources managers that we interviewed also attended training seminars or courses in order to learn more about the fit note and its impact on organisations. For example, one manager attended an ACAS course while another attended an update course on absence

19Preparation for the fit note

management. The size, industry and sector of these organisations varied. Such training was not usually extended to line managers or staff. There were two exceptions to this: one human resources manager from a large public sector organisation indicated that they had provided internal training on the fit note to line managers through the organisation’s intranet while another manager from a medium-sized charity mentioned that they had organised an ACAS training session on the fit note for all employees. In the case of the former, this was likely to be because the large size of the organisation meant that line managers would be the ones initially receiving and dealing with the fit note rather than the human resources department. In the latter case, the manager stated that he had organised this training because he was trying to make changes to the organisation’s sickness absence policy such as introducing back to work interviews and saw the benefit of making these internal changes at the same time as introducing staff to the fit note.

Since the introduction of the fit note, most of the organisations interviewed had not taken any action to modify their sickness absence system. A few large public sector organisations indicated that they planned to or had already made changes to their system. One organisation described how they planned to modify their human resources records system in order to record the number of fit notes they received which suggested adjustments as well as recording the total number of fit notes received as they already did. Another organisation stated that they had changed their sickness absence policy because some of the fit notes they had received suggested that individuals should work reduced hours for long periods of time. Although employees working reduced hours previously received full pay, the policy has been changed so that such individuals now only receive full pay for a period of four weeks. Beyond this point, working reduced hours was counted as sick leave and after an absence period of six months employees began to receive half pay.

3.4 Guidance published by the DWP on the fit note Organisations that had seen the DWP guidance on the fit note generally commented positively on it, stating that they found it useful and informative. The reasons for this varied, as did the size, industry and sector of the organisations: some organisations found it useful because it was the first time they had seen an example of what the new fit note would look like, while others commented that they found it to be a clear and straightforward explanation of the changes that were coming into effect. However, one large public sector organisation felt that the guidance was not comprehensive enough:

‘Frommypointofview,therewerestillalotofunansweredquestions.AndIthinkthatwasdowntothefactthatitwasquiteadeparturefromthewaytheGPshadbehavedinthepast.’

20 Employees’ discussions with GPs about fitness for work


Key points• Some employees interviewed in this study had discussions with their doctor about returning

to work in a reduced capacity; others did not.

• Discussions about returning to work in a reduced capacity usually took place towards the end of the individual’s sickness absence period. The topic of returning to work was raised by individuals, GPs and, in some cases, by both. Some individuals also received advice from other healthcare professionals, including occupational health practitioners, which prompted them to raise the issue of return with their GP.

• The content of discussions varied: some GPs asked their patients about their job and what it entailed; others did not. Similarly, discussions about changes to an individual’s job to assist return varied considerably in detail. Some GPs simply suggested a single course of action while others had a detailed discussion about the types of changes that would be most appropriate to the patient’s job.

• In some cases, discussions with GPs were led by the changes suggested by other healthcare professionals. In these cases, GPs simply facilitated the changes that had already been discussed between the individual and their employer.

• The amount of detail provided by GPs on fit notes varied considerably. Some GPs simply ticked the relevant adjustments while others provided detail in the space for comments. Employers also felt that a few GPs did not complete the fit note correctly.

• Discussions about returning to work in a reduced capacity had various effects on employees. In some cases, it enabled them to return to work earlier than they otherwise would have done or helped them to raise the issue of returning to work in a reduced capacity with their employers. In a few cases, individuals believed that the adjustments suggested had delayed their recovery process.

As indicated previously, one of the key objectives of the fit note is to reduce sickness absence and support people with health conditions to stay in work or return to work quickly. As such, GPs should consider individuals’ fitness for work and, where appropriate, have discussions with their patients about the possibility of returning to work in a reduced capacity. Such discussions can require knowledge of an individual’s job and the possibility for adjustments within their workplace.

This chapter draws primarily on the interviews conducted with employees within this study. It explores the discussions which took place between GPs and employees about returning to work in a reduced capacity. In doing so it looks at the procedure, content and impact of these discussions as well as the content of the fit notes received by employees and the assistance suggested by GPs. The chapter concludes by briefly examining employees’ views on the understanding and advice they received from their doctor.

21Employees’ discussions with GPs about fitness for work for the fit note

4.1 Procedure of discussion with GP

4.1.1 Timing of discussionsSome employees had discussions with their GP about returning to work in a reduced capacity. In instances where such discussions took place, they usually occurred towards the end of the individual’s period of sickness absence. In some cases, the discussion took place a few weeks before the individual was thinking about returning to work or a few weeks before their existing fit note expired. In other cases, the discussion took place immediately prior to their return to work.

There were a few exceptions where discussions about returning to work took place early on in the individual’s period of sickness absence. Although the conditions and jobs of these individuals varied, all of these cases involved individuals who were keen to return to work as soon as possible and they, themselves, prompted discussions with their doctor. Such a finding mirrors the view of some employers and GPs who felt that the motivations of the individual played a role in the outcome of the situation and that individuals who were keen to return to work tended to do so earlier on in their recovery process. In addition, one individual indicated that they had a discussion about returning to work each time they visited the GP during their recovery period. These discussions were led by the individual who was a single mother who was concerned that she was becoming unemployable after having been off sick three times in the past three years. Fylan etal. (2011) found that some GPs used the fit note to introduce the topic of returning to work early on in their recovery process because it can prime patients for a more detailed discussion on the topic in the future. However, in our study employees did not report early use of the fit note being instigated by GPs.

4.1.2 Who raised the issue of returning to work In-depth qualitative research with GPs suggests that the fit note has become a consultation tool which GPs use to initiate and guide discussions with their patients about returning to work (Fylan etal., 2011). In the present study, interviews conducted with employees revealed that the topic of returning to work was sometimes raised by the GP; in other cases it was brought up by the patient or discussion of the topic was initiated jointly. In some cases where return was brought up by the individual, GPs responded by discussing returning in a reduced capacity and by suggesting adjustments to the individual’s job:

‘I’mprettysurethatmyGPactually,whenwefirststarted,whenIactuallysaidthat,whenIintimatedthatIwantedtothinkaboutreturningtowork,itwasactuallyhimthatsaidthatyeah,hethoughtitwasagoodidea,butonlyifIdiditveryslowlyandgradually,i.e.underanagreedphasedreturn.’

Individuals who were keen to return to work were more likely to raise the issue of returning to work. The conditions and jobs of these individuals varied as did their reasons for wanting to return to work. Some disliked having time off and preferred to be at work, others indicated that they were bored at home and others still felt pressure to return to work from their line managers or put pressure on themselves to return to the workplace as soon as possible. In some cases, individuals indicated that they had ‘persuaded’ their GP to allow them to return to work, usually in a reduced capacity. This tended to occur in cases where individuals were in the early stages of recovery and their doctors were not initially convinced that they were ready to return to work. Such a finding is in keeping with Fylan etal. (2011) who showed that in cases where individuals were keen to return to work, GPs helped them to do so. Self-employed people were also seen by GPs as being particularly keen to return to work as soon as possible, especially when compared with their employed counterparts.


Some individuals also specifically raised the issue of returning to work in a reduced capacity and indicated to the GP that they felt there was a need for adjustments to be made to their jobs. This tended to be in cases where individuals had prior experience of having adjustments made to their jobs or through knowledge of human resources practices. For example, one employee from the voluntary sector who had experience of human resources management wrote to his GP suggesting a six-hour restricted day for a period of two weeks following recovery from a car accident.

There was also one case in which a discussion about returning to work in a reduced capacity was raised by both the GP and the individual. Upon being asked about who had raised the topic, the individual replied:

‘Abitofboth,becausewhenI,aftermyoperation,Ireallywantedtogetback,sowekindoftalkeditthroughtogetheraboutwhatmightbesuitabletokindofgetbackintowork.’

In some cases, the discussion of returning to work in a reduced capacity was prompted by advice that employees had received from other healthcare professionals including occupational health advisers at work, physiotherapists, osteopaths, police force doctors, and fire and rescue service doctors. These cases tended to involve individuals working for large organisations who provided an occupational health service for their employees or individuals who could afford to pay for treatment such as osteopathy. Although these individuals had various jobs, several had physical injuries. In cases where individuals had received advice from other healthcare professionals, the individual usually raised the subject of returning to work in a reduced capacity and indicated to the GP that they had already had a discussion with another healthcare professional about the possibility of making adjustments to their job. In these instances, there was usually little discussion about the nature of the adjustments, with the GP readily agreeing to write a fit note outlining the adjustments that had been agreed by the individual and their employer. For example one individual indicated,

‘It[the details]wasverymuchleftuptomeandmyemployerandmyoccupationaltherapistwhoaskedmetogetthatfitnotesothentheycouldstartthephasedreturn.’

There was also one case in which the GP advised a police force employee to talk to the force doctor about the adjustments that would be appropriate for his job. In this instance, the GP simply put ‘restricted duties’ on the fit note and left the details to be decided between the individual and the force doctor.

In other cases where external advice was involved, individuals indicated that the decision to return to work in a reduced capacity was very much a collective one:

‘Itwasacollaborativeeffortreally.IthinkthefirststepwasIspoketomyGPandsaid“I’mthinkingaboutgoingtowork.IfI’mthinkingaboutthesetimescalesdoyouthinkthat’ssensible?”Sheagreeditwasreasonableandsaidtoseewhatoccupationalhealthsay.OccupationalhealthissuedthereportwhichshesharedwiththeGPandtheGPsaid:“They’realongthelinesofwhatwe’rethinkingandifyou’rehappywiththatthenwe’llgowiththatasplanA”.’

In these cases, the individuals concerned had a variety of jobs and health conditions but all health conditions were of a serious nature, for example some individuals had undergone major surgery.

4.2 Content of the discussion Discussions about returning to work in a reduced capacity initially focused on how the individual was feeling, whether they felt ready to return to work and when they were planning to return. Drawing on in-depth qualitative interviews with GPs, Fylan etal. (2011) described how the recent


shift in the focus of consultations to include discussions about work allows GPs to gain greater insight into the patient’s job. However, they also found that some GPs believed they only needed to give limited guidance on the fit note and as such felt they only required a basic level of information about the patient’s job. Our discussions with employees indicated that only some GPs asked the individual about their job and its physical requirements such as travel. This tended to be in cases where individuals had physical injuries or had undergone surgery. Following this, GPs usually went on to suggest changes that they thought could be made to individuals’ jobs in order to facilitate their return to work.

In other cases, employees said that the GP did not ask any questions about their job. The health conditions of these individuals varied from minor ailments such as flu to major surgery. However, some of the individuals with more serious conditions indicated that their GP had known them for a long period of time and that the GP was already familiar with their occupation.

Discussions about changes to an individual’s job to assist return to work varied in detail. The level of detail appeared to depend more on the individual approach of the GP than on the employee’s condition which varied quite considerably. In some cases, the GP suggested a single course of action while in others the GP had a detailed discussion with the individual about what changes would be feasible and most appropriate to the individual’s job and condition. In cases where the employer or the employer’s occupational health adviser was keen to facilitate changes to an individual’s job, the GP tended to either suggest a course of action, leaving the details of the change to be negotiated between employee and employer or simply facilitated the changes which had already been discussed by the individual and their employer by completing a fit note for them. Such individuals worked in a range of industries and sectors but had generally been off sick for more than four weeks and tended to be recovering from surgery, illness or have a mental health condition.

As indicated previously, in some cases, there was no discussion between the GP and the employee about returning to work in a reduced capacity. The jobs and conditions of these individuals varied considerably. Some indicated that they did not think such a conversation would have been appropriate either because they felt that their condition would have prevented them from returning to work at that stage, even in a reduced capacity, or because they were completely recovered and simply wished to return to work full time. However, two individuals did indicate that such a discussion would have been helpful. Both individuals worked for the same private sector organisation. One of the individuals had electrocuted himself, the other had injured her back. Both stated that they would have found adjustments to their job helpful and one of the individuals stated that he thought this would have enabled him to return to work sooner. Such a finding suggests that further training for GPs on the importance of such discussions might be helpful in achieving the policy objectives for the fit note.

4.3 Effect of discussion with GPDiscussions about returning to work in a reduced capacity had various effects on employees. Some employees indicated that their discussion with the GP had led to a positive outcome. In some cases, this was because the changes suggested by their GPs enabled them to return to work earlier than they would otherwise have done. The jobs and conditions of these individuals varied significantly. In other cases, this was because the fit note they received enabled them to raise the issue of returning to work in a reduced capacity with their employer. Both the individuals who mentioned this worked for a large charity which had occupational health support: one had been off sick for six months with osteoarthritis, the other for two months with a prolapsed disc in their back. Some individuals, with various conditions also indicated that the adjustments to their job enabled them to ease back into work and prevented them from having to go off sick again for a period of time. Indeed, one individual described her experience of a phased return saying:


‘Thefirstweek,workinguntillunchtime,IwasabsolutelyonmykneesbutthenIcouldgohomeandrestintheafternoonandIwasokayagainforthenextday.IfIhadn’tdonethat,ifI’dtriedtocomebackanddofulldays,IsuspectI’dhavelastedaboutthreedays,andI’dhavebeenoffsickagain.Imean,youcan’tknowthesethings,butthat’smyfeeling.’

Other employees with various conditions described how their discussion with the GP simply helped ratify changes suggested by other healthcare professionals such as an occupational health adviser or a force doctor and thus the patient’s discussion with their GP was perceived to have little additional effect. For example, one individual indicated that he was not sure whether a discussion with the doctor was useful since all he needed from the GP was a fitness for work certificate:

‘No,Idon’tknowtobehonest...IthinkbecauseitwasmydecisiontoreturntoworkandIjustneededtogetthecertificateoffmydoctortoreturntowork...itwasultimatelygoingtobedowntomydiscussionwiththebrigadedoctorastomychoiceaboutreturningtowork.’

Two individuals also indicated their belief that the adjustments suggested by the doctor during their discussion had delayed their recovery process. Such a finding indicates the potential risks associated with the fit note and its emphasis on getting people back into work as soon as possible. In both cases, the individuals worked for private sector organisations and felt it was important to go back to work as soon as possible. The first of these individuals, who had fractured her leg, did not want to take time off from work because she had recently started a new job. The second, who had suffered an injury to her neck, was concerned about taking too much time off work for fear of losing her job at a time when firms were making cutbacks. She indicated that her osteopath and GP listened to these concerns and suggested a phased return which enabled her to return to work quicker but resulted in a longer recovery period:

‘Ithinkthephasedreturnactuallyprolongedmyneckinjury,becauseIdidgo,IwasoffonNovember4thwithitandIstillhaditinJanuary...andthebuzzinginmyarmcausedbythetrappednervedidn’tgountiltheFebruary....Ithinktheactualdoingwork...helpedforme,eventhoughitmighthave,ifI’dhadjustsixweeksstraightitwouldhaveprobablybeenquickerIthinkhealing.’

4.4 Assistance suggested GPs suggested a range of adjustments to individuals’ jobs in order to facilitate their return to work including phased returns to work, altered hours, altered duties, home working and workplace adaptations.

GPs suggested phased returns in cases where individuals had mental health conditions, had undergone major surgery or had a chronic physical condition or injury. Phased returns were generally suggested to individuals working in a range of non-manual jobs. Reduced hours were also suggested by GPs in cases where individuals in a range of non-manual jobs had undergone major surgery while amended duties were suggested in cases where the individual’s occupation entailed manual work such as in the case of a care worker and a fire station manager.

4.5 Fit note content Individuals were generally either signed off work by their GP for a period of time and received one or more fit notes with the ‘not fit for work’ box ticked. Some individuals also received a final fit note with the ‘may be fit for work’ box ticked and adjustments suggested. There were, however, two cases in which employees reported that the GP did not tick either the ‘not fit for work’ box or


the ‘you may be fit for work’ box. In the first of these cases, the intention of the GP was to sign the individual off from work because of depression while in the second case, the GP had simply written ‘post-operative recovery’. Such examples highlight some employers’ concerns that GPs were not completing fit notes adequately. One individual also indicated that they had received an old sick note from the hospital and that their employer had asked them to return to the GP for a fit note.

The level of detail provided on the fit note varied considerably with some GPs simply ticking the relevant adjustments such as a phased return to work while others provided detail on the number of hours an individual should be working and on the pattern of the phased return. Since the health conditions of these individuals varied quite considerably, the level of detail provided appeared to have more to do with the individual approach of the GP. Indeed, Fylan etal. (2011) show that some GPs believe there is only a need to provide limited guidance on the fit note.

In cases where individuals were signed off as ‘not fit for work’, the nature and severity of the sickness appeared to be linked to the length of the spell covered by the fit note. In some cases, the length of time that individuals were signed off reduced as the patient began to recover.

4.6 Employees’ views on doctors’ understanding of their health condition and advice

Most of the individuals who were interviewed felt that their GP had a clear understanding of their condition and offered them sound, appropriate advice. These individuals had a variety of occupations and health conditions. For example, one individual who was recovering from cancer-related surgery commented that they felt more confident about returning to work in a reduced capacity following their discussion with the doctor:

‘IthinkhewasveryhelpfulactuallyandhavingspokentohimIactuallyfeltbetteraboutgoingbacktoworkandjustdoingwhatIcould,andthenjusttakingtheodddayoffhereandtheretorestmyhandwhenIneededto.’

One individual also commented on the fact that their doctor had always made a point of asking them exactly what their job entailed and that this had helped them get back to work as quickly as possible:

‘IthinkmyGP,whicheverpracticememberIhaveseen,theyhavealwaysmadeapointofaskingmeexactlywhatIhavedoneforajobandthenatureofhowmuchindoors,howmuchoutdoorsandthedistancesthatIhavebeendriving...andtheyhavealwaysbeenverythorough...andso,ithasalwaysbeenacaseoftryingtogetmebacktoworkasquicklyaspossible,withinmylimitationsyouknow.’

However, in a few cases, individuals, with a range of health conditions and occupations, felt that their doctor demonstrated poor understanding of their illness and provided inadequate fitness for work advice. In some cases, this was due to the way in which the doctor had completed the fit note, and in particular because the doctor did not suggest adjustments to their job which they felt would have been appropriate. For example, one individual commented that she thought her GP had treated the fit note like the old sick note and simply signed her off from work. She went on to add that it would have been useful if the GP had suggested reduced hours during the week that she returned to work because she was still experiencing some pain from her injury upon returning to work.

In other cases, individuals felt that the doctor did not sufficiently understand their health condition and as a result thought they were offered inappropriate advice. For example, one employee with


post-viral fatigue described how one of the doctors she had seen tried to treat her for depression instead of offering advice on post-viral fatigue:

‘Imeanoneofthedoctorsjustsaid,“oh,you’vegotdepression,herehavesomeantidepressants”.It’slikeer“no”.’

One individual also commented that one of the doctors she had seen refused to give her a fit note which suggested a phased return, even though she had already discussed this course of action with her regular GP and her occupational health adviser. She described the situation as follows:

‘IdidseeoneotherGPduringthistimeanditwasacompletedisastertryingtogethimtofillinthefitnotebecausehedidn’tunderstandhowitworked.ItwasquiteatraumaandactuallymyGPrangmebacksayingitwasacaseofthemnotunderstanding.HerefusedtogivemeafitnotebecauseIwasworking;hesaiditwasforwhenyouweresick.’

Only two employees interviewed had experience of discussions about a phased return with their GP under the old sick note system. One, with a desk-based job, described having a phased return following a motorcycle accident. In this case, both the GP and the employer had been involved in the discussions. In the other case, the individual had a discussion with their GP about altering her duties due to a nerve problem in her arm. She indicated that this particularly involved reducing her computer usage since she was in a desk-based job. She also commented on the fact that she did not think that there had been much difference between their recent discussion with their GP and her previous experience. However, she did add that she had not had much experience of the sickness absence certification system since she was rarely off sick for long periods of time.

27Fit note content: employers’ experiences and views

5 Fit note content: employers’ experiences and views

Key points• Employers received few fit notes stating that an employee ‘may be fit for work’.

• Employers believed the GP/patient relationship inclined GPs to follow employees’ wishes and placed the employer at a disadvantage.

• Employers believed GPs lack information about job roles, work organisation and occupational health more generally, making it difficult for them to assess fitness for work or suggest adjustments to assist return to work.

• Employers felt that the information on the fit note was often inadequate, consisting only of ticked boxes and with no guidance on adjustments such as activities to avoid.

• Employers varied in how detailed they wished suggested adjustments to be.

• Despite dissatisfaction with the quality of completed fit notes, many employers saw the fit note as a positive step in encouraging discussions about work and possible adjustments to take place between GPs and patients, which could lead to an earlier return to work.

In this chapter we focus on employers’ experiences of receiving fit notes for their employees, their views on GPs’ use of these and the feasibility of making any suggested adjustments.

Three main themes were apparent from our interviews with employers: First, the small proportion of fit notes which recorded an employee as ‘may be fit for work’ rather than ‘not fit for work’; second, the practicalities of making changes to enable an employee to be classed as fit for work; and third, the adequacy of information provided by GPs. Additional issues discussed with employers in relation to the fit note content, and reported here, included the contact between employers and GPs, employers’ views on GPs’ role in relation to patients and sickness absence and suggested changes for improving current practice. These are discussed in turn below, after a brief description of the extent of employers’ experience of the fit note.

5.1 Extent of employers’ experience of the fit noteTo participate in the study, organisations had to have received a fit note. However, few knew how many they had received. Approximately half of the employers interviewed were unable to provide any indication of the number of fit notes they had received, although some employers were able to provide us with an approximate number because they had collated them or analysed prevalence or content. This was the case in our sample for organisations of all sizes, industries and sectors.

In the cases where organisations were able to tell us how many fit notes they had received, the overwhelming majority of them indicated that the number of fit notes they had received where the doctor had ticked ‘may be fit for work’ and suggested adjustments represented a very small percentage of the overall number of fit notes received. For example, one employer had received more than 252 fit notes at the time of our research, 35 of which had included fitness for work advice. The experience of receiving very few fit notes advising ‘may be fit for work’ was the case in our sample for organisations of all sizes, industries and sectors. Some of the organisations who


did not know how many fit notes they had received also reported that very few indicated ‘may be fit for work’ and suggested changes. There were a few exceptions to this: two organisations indicated that 50 per cent or more of their fit notes had suggested adjustments to facilitate an early return to work. A third organisation indicated that it had received a large number of fit notes with adjustments but was unable to provide an exact percentage.

5.2 Fit note content: GPs’ use of the ‘may be fit for work’ optionEmployers felt that GPs made little use of the may be fit for work option on the fit note, and believed that there were two main reasons for this:

• the GP/patient relationship; and

• GPs’ lack of knowledge about the workplace, job roles and work organisation.

On the first of these, many employers believed that on the question of fitness for work, GPs are guided principally by the expressed wishes of their patient rather than by an assessment of the patient’s capacity for work, and of the effect of their work on their health condition. Therefore, employers believed that where an employee wished to be signed off work, a GP would acquiesce to this. Some employers believed that the ‘may be fit for work’ advice was only made where the employee had explicitly said to their GP that they did not want to be off work and believed that this typically occurred when an employee’s Occupational Sick Pay (OSP) was running out. Employers also remarked that GPs appeared to be particularly reluctant to advise adjustments where mental health conditions were involved, and believed that, in such cases, GPs were guided particularly strongly by the patient’s wishes.

Lack of understanding among GPs of the workplace and of job roles was a second reason hypothesised by employers to explain the perceived low use of the ‘may be fit work’ option. Employers did not generally criticise this lack of understanding, reasoning that GPs are not occupational health experts and cannot be expected to understand the job content, working conditions and arrangements of their many patients. Employers felt there was particular lack of understanding of potential adjustments to work. Some employers also felt that GPs were nervous of making recommendations without sufficient knowledge of work demands. It was argued that GPs were risk-averse and were concerned that they will be blamed should a patient’s health be damaged by working while in poor health.

It was felt that GPs are overly reliant on their patients for information and some employers thought that the nature of the information patients provided to GPs depended on whether they wished to return to work. Similarly, in-depth qualitative research with GPs revealed that many thought that the patient’s agenda for employment determined the effectiveness of the fit note in enabling early return to work. One employer in the public sector said:

‘Ithinksomepeoplewanttocomebacktoworkbecausethey’regenuinelysicktodeathofbeingsatathomeandthink,“Well,IcoulddothisifIwentbacktoworkandIcoulddoalittlebitofajob”.Others,theirmoney’srunningout,soiftheycangetbacktoworkwhilstthey’restillinfullpay,theycandoaphasedreturn,workinglesshoursfortheirfullsalary.’

Some employers were more critical of what they felt was GPs’ lack of effort to understand their patients’ jobs and that it was simply easier to sign them off work altogether. To improve GPs’ understanding of job roles and to recommend adjustments more often, one employer, a large retail group call centre, had contacted GPs to explain the variety of roles within the organisation, by means of an organisational brochure, and through letters from their occupational health department describing the opportunities for ‘light duties’.


Some employers expressed disappointment that they had received so few fit notes advising may be fit for work because they felt the fit note offered an opportunity to enable employees to continue with their normal lives and that, in some cases, working could hasten their recovery. One employer expressed frustration that GPs appeared to overlook the benefits of working over inactivity and had tried to address this through issuing a reminder to GPs:

‘IquiteoftenthinkthatGPsactuallydon’tconsiderworkandyetit’ssuchahugepartofsomebody’swellnessandtheirmentalhealthandIdon’tknowifGPsseemtoforgetthatit’sactuallyhealthierforsomebodytobeatworkthannotatwork.AndIgettothepointwhereIactuallywriteinthatreport,“doyourealisethattheevidenceshowsthatit’sactuallyhealthierforsomebodytobeatwork?”AndIjustthinksurelytheseguysknowthis.’

However, as we explain in Chapter 8, it was also felt that employees sometimes return from sick leave too soon.

There were a few exceptions, where employers reported that a sizeable proportion of the fit notes they had received had advised ‘may be fit for work’. These cases fell into two groups: employers who involved their own occupational health services in return to work plans; and employers who provided no occupational sick pay. Those in the first group included a large accountancy firm with an in-house occupational health department which actively engaged with employees and GPs around return to work plans. Employees from the firm confirmed that their discussions about return to work had been largely with occupational health advisers rather than with human resources or line managers. Another large employer, in the public sector, did not automatically accept ‘not fit for work’ notes but sought advice from its occupational health provider, with a view to exploring adjustments and an earlier return to work. However, having an occupational health service engaged with employees’ return to work plans did not always affect GPs’ use of the fit note. An orchestra reported that it had received no ‘may be fit for work’ notes even where an employee had already discussed a phased return to work with the orchestra management and occupational health department.

Other employers who had received ‘may be fit’ advice from GPs were generally smaller, private, organisations, providing no OSP. Among this group were care homes and a market garden. The care homes frequently received fit notes advising adjustments. These were typically ‘light duties’ which, as we explain in the next section, some employers found difficult to accommodate. These employers believed that the suggestion of ‘light duties’ was that of the employee rather than the GP’s own assessment.

5.3 Practicalities of changes to workMany employers commented on the practicalities of the recommendations made by GPs to help people return to work. Employers could generally accommodate altered hours. Employers also said they could accommodate phased returns to work and a few amendments to duties, although many had not been asked to make such amendments. Some employers were not able to offer any alternative duties. These included organisations with a small administrative function, such as care homes, farms and an orchestra.

Some employers said that they experienced difficulty in making other changes to employees’ duties, particularly those which involved a change in tasks and duties. One view of employers was that the amendments suggested by GPs were sometimes impractical. The suggestion of ‘light duties’ was the adjustment that presented most difficulties for some employers. A number of employers in the health and social care sector said that they had not been able to offer light duties to care assistants whose work involves lifting residents, or to laundry staff who have to carry bed linen and operate heavy machinery. One employer reported that some suggested amendments were not possible,


citing the example of an employee in a customer-facing role who was advised to have no contact with the public. However, the reports of some employees of this organisation suggest some degree of inflexibility on the employer’s part in finding alternative duties.

Some employers felt that some suggestions for alternative duties were made by the employee rather than by the GP. Another view was that the GP had suggested changes which were based on assumptions about the work, or lack of understanding about what changes might be practical, given the nature of the work and organisation. One employer felt this could be resolved simply by the GP asking patients appropriate questions to reach understanding of possible adjustments.

A further concern by some employers was that the amendments would be harmful to an employee’s health and impede their recovery, even though recommended by their GP. Examples of this concern included the case of a care home employee experiencing a difficult pregnancy and advised to carry out light duties.

One view of employers was that the ‘may be fit for work’ advice sometimes raised employee expectations that they will be given alternative duties and that they were disappointed when these were not offered. It was argued that GPs should make it clear to patients that the suggested amendments are conditional on their employer being able to accommodate their request.

Another view expressed by employers was that the ‘may be fit’ advice gives too much control to the employee, particularly where the GP’s advice is vague. Some employers felt they were obliged to rely too heavily on the employee’s account of the GP’s recommendation. One employer felt that an employee had over-stated their GP’s advice to work reduced hours, and had taken advantage of the time off work to organise her wedding. Such a perspective reflects some GPs’ concerns over the fact that the fit note effectively requires employees to act as a ‘conduit of information’ between the employer and GP since there is rarely any dialogue between GPs and employers over a patient’s case (Fylanetal., 2011, p. 42).

5.4 Adequacy of information from GPsOne of the main themes in discussions about the fit note was the feeling that the information provided by GPs was not detailed enough. Many employers reported that where the ‘may be fit for work’ box was ticked, GPs frequently ticked boxes indicating a phased return, altered hours, amended duties or workplace adaptations, but provided either no further guidance or very little of any use to the employer.

A main concern of employers was the lack of detail about what tasks an individual should or should not do and how work might be adapted to meet the individual’s needs. A number of employers commented that the information provided by the GP was usually nothing more than the wording on the fit note boxes, indicating that the individual may be fit for work with adaptations or amended duties. Employers said they would like more guidance about the type of adaptations which might be suitable. One employer described the consequences of having this type of fit note:

‘Doctorswriteonthem‘possiblyfitforworkwithadaptations’,buttheydon’tactuallytellyouwhattheythinkthoseshouldbe.Thentheemployerislefttokindofreadbetweenthelinesandsometimesyougodownthepathofleastresistancebecauseyouthink“whatifIgetthiswrongandImaketheirsituationortheircircumstanceworseandtheycouldblamemeandlitigateagainstme?”Sotheeasiestrouteisjustsayactuallywecan’tmakeanyadaptations,soyou’reoffsick,whichiswrongbecausetheemployeedoesn’twanttobeoffsick.’

3Fit note content: employers’ experiences and views 1

Some employers said they would like to be able to talk directly to an employee’s GP about what amendments might be both practicable from their point of view and suitable for the employee. However, this dialogue was generally not possible, as we explain later. A number of employers said that, where advice about adaptations was unspecific, they would talk directly to the employee and would sometimes ask employees to obtain further guidance from the GP. However, as described earlier, some employers were concerned that this gave too much power to individual employees.

One view expressed by employers was that GPs do not provide sufficient guidance on adaptations and amended duties because they do not have enough knowledge of the workplace and of possible options. While this made some GPs reluctant to suggest adaptations, it was thought that other GPs made assumptions about jobs, particularly those seen in the public eye as active, for example police or fire fighters. As one employer explained:

‘Youtalkaboutfirefightersandpeopleimmediatelyhavethisimageofsomeonesquirtingwaterataburningbuildingand,iftheycan’tdothatthenthey’renotfittoreturntoworkandthatverymuchisnotthecasereally.’

One employer, from a healthcare provider, suggested that GPs could have a directory of physical and mental conditions with possible adjustments enabling individuals to work.

Although some employers felt that GPs’ lack of occupational health knowledge could not easily be addressed, it was felt that GPs could nonetheless provide more specific information on the capabilities of patients who are given fit notes. For example, two fire services felt that GPs could provide more detail about a fire fighter’s physical capabilities and the functional effects of their health condition, rather than simply write them off as not able to perform fire-fighting duties. This would allow employers to make a better judgement on an employee’s fitness for particular duties, rather than assuming they are only capable of doing sedentary work. One employer felt that more detail could also protect employees who are too keen to return to work before their health should really permit:

‘IwouldprefertheGPtobemoreprescriptivebecause,attheendoftheday,wearenotdoctorsandsometimessomeemployeesdon’talwaystaketheirhealthasseriouslyastheyshould.’

Employers with access to occupational health guidance, particularly through in-house provision, were in a more advantageous position than others. These employers felt more at ease with interpreting GPs’ recommendations, or would override them on the basis of assessments provided by their own occupational health advice. The view of some of these employers was that the GP could not be expected to provide a detailed assessment and that it was appropriate that assessments should take place within the workplace, with occupational health guidance. Some employers without access to occupational health support were uncertain about whether they should treat GPs’ advice simply as guidance or as a recommendation with which they should make every effort to comply.

We have focused so far on the problems which some employers had in responding to recommendations of alternative duties, particularly the lack of guidance provided by GPs. Employers also complained of insufficient guidance on recommendations of phased returns and altered hours. Fit notes were reported to rarely include suggested working patterns (for example half days, late arrival and early departure or shorter working week). A further problem for employers was lack of guidance about the period of time suggested changes in hours should last for. Again, in such cases, some employers asked employees either for their own interpretation of the GP’s recommendations or to return to their GP to obtain more detailed guidance. One employer, in the healthcare sector, described an example of what they felt was good practice in relation to recommendations of phased returns to work and altered hours:


‘Itneedstobemeaningfulaswell.Thereneedstobereasoningbehindwhythey’resayingparticularmornings,afternoons.Ihadaverygoodoneafewmonthsagowheretheywereveryclearthatthey’dworkmorningsthefirstweekandthenthey’dworkafternoons,gettingthemusedtoworkingatdifferenttimesbecausetheywerecomingbackafteralengthyperiodwithdepression.Thedoctorhadbeenverygood,they’dlistedallthisandthatwasincrediblyhelpful.Butwe’vehadcaseswheretheyjustsay‘onreducedhours’.’

Therefore, some employers felt that a rationale for the GP’s recommendation would be helpful in designing altered working arrangements for an employee.

5.5 Other aspects of GPs’ use of the fit noteWe have outlined several ways in which the advice given on the fit note was seen as problematic by employers. Employers also identified several other issues with the use of the fit note by GPs, including the legibility of GPs’ handwriting.

One common concern was that employees are sometimes signed off work for excessively long periods without adequate explanation or without provision for a GP reassessment. Employers found that the fit note was sometimes not completed fully, with sections left blank, including dates of absence and return. Qualitative research with GPs indicated that they themselves expressed uncertainty about completion of different parts of the form including date fields and return to work options. Some GPs also experienced section blindness meaning that they regularly left parts of the form blank (Fylan etal., 2011). They reported that it was common practice for GPs to not complete the part of the fit note stating ‘I will/will not need to assess your fitness for work again at the end of this period’. The aforementioned research with GPs also found that many were unsure as to whether this section of the form was mandatory since patients were not usually reassessed after the specific time period of sickness (Fylan, etal., 2011). Employers said it would be useful to have this information because it might indicate that a further period of absence was possible and could affect how the sickness absence was addressed.

Employers also felt that GPs’ use of terminology in relation to some health conditions could be improved. The use of Latin terms by some GPs was found particularly unhelpful as were vague diagnoses such as ‘low mood’ or ‘debility’. Although employers were aware that this may be intended to protect patients from the stigma of mental illness, they argued that lack of clarity about reasons for absence were not in the employees’ interests.

Discussions with employers generally revealed negative experiences of the fit note and their use by GPs. However, it is important to note that many employers saw the fit note as a positive step. The fit note was seen as encouraging discussions about work, and possible adaptations, to take place between GPs and patients, which could lead to an earlier return. A number of employers said they welcomed guidance from GPs about amended hours and duties, since these could make a difference to rates of sickness absence and were good for employee morale and well-being. The representative of a Government department stated:

‘Havingthe‘mightbefitforworkwithadaptations’isafantastichelp.Weinthisdepartmenthadsomedisappointmentwiththelownumberbecausethey’restilltheexceptionthatyougetratherthanthenorm.Youdidn’thavetheoptionbeforesoit’sanimprovement.Ithinkit’sawin,win.Evenifyouonlyhaveonefitnoteoutofahundredthathasthaton,thenit’sonewewouldn’thavehadbefore.’


Other employers agreed that the information provided by GPs could sometimes be very useful in making adaptations and enabling an earlier return to work. We described earlier how some employers felt that the information provided by GPs was too often inadequate. Among the employers which found the fit note most useful were those who had received very specific guidance on adaptations, such as ‘less PC work’ or ‘less talking’. However, some employers felt that it was best that GPs did not make precise suggestions, since these might not be appropriate or practicable. As one employer in the private health sector explained:

‘GPstypicallyarenotoccupationalhealthspecialistsandcan’tbeawareofeveryjobthateveryemployeedoes.IthinkitwouldbeverydifficulttogiveaGPmoreinformation.Thejoyofwhatwehaverightnowisthatit’sflexibleenoughforustointerpretandfittheGP’srecommendationwithinthecontextofourbusiness.IftheGPwastickingmoreboxesmaybe,orbeingmorespecificaboutinstructions,itmightprovelessusefulbecausewe’dneedtobemanaginganemployee’sexpectationtosaythat’snotpracticalorreasonableorfeasibleinthecontextofourbusinessorinthecontextofyourjob.’

This employer may have had an advantage, however, of being in the health sector and of, therefore, understanding the conditions described in the fit note.

5.6 Contact between employers and GPsWe have described how some employers felt they had inadequate information about an employee’s ability to do their job and about the appropriateness of adaptations. In some cases this led to discussions with the employee.

Employers said that, ideally, they would like to have a discussion with an employee’s GP about adaptations. However, they understood that General Medical Council (GMC) guidelines do not permit such discussions. Where employers had occupational health services, either in-house or through an external contract, exchange of information between GPs and the employer was quite common. This was with the express permission of the employee. These exchanges consisted usually of requests for medical reports. These were reported to be often late in arriving (sometimes making the report redundant) and of varying quality and usefulness. Employers were irritated by the lateness and vagueness of some GPs’ reports, feeling that they were not helpful to the employee. This also resulted in employers not asking for reports, when good information, provided quickly would have been useful in deciding on an employee’s activities. Some employers also saw contact with the GP as an opportunity to explain the support that could be provided from within the workplace, but did not know whether GPs found this information useful.

5.7 What employers would like from GPsWe have described a number of ways in which employers felt GPs might improve their practices in relation to completing the fit note, for example through completing all relevant sections and recommending ‘may be fit for work’ in more cases. Some employers had a number of specific suggestions about how practices around the fit note could be improved and how GPs might help employees to return to work. These suggestions included:

• occupational health specialists located within GP practices to give more detailed and practical guidance to employers;

• the fit note to include a box to indicate that the GP is willing to discuss potential adaptations with the employer;


• for the process of deciding on fitness for work to be a more interactive process and include dialogue between the individual, the GP and the employer;

• for more contact between employers and GPs through partnership sessions aimed at improving understanding of the role of all parties in sickness absence and how they might work together for the benefit of employees.

On the third suggestion, one employer argued:

‘Thefitnotesaresignedbythewrongpersonontheirown.Idon’tseehowanybodycansayapersonisfitforworkunlesstheyunderstandwhatthedemandsoftheworkareandthatshouldbeatleastatwo-wayconversationbetweentheemployer,theemployee,theGPortheconsultant.Butatthemomentitisn’t.Wearethepassiveonesandwesithereandwewaitforthisthingtoarriveandseewhatitsays.’

We were not able to consider the feasibility of this suggestion, but our research findings suggest that some employers would be in favour of this kind of dialogue with doctors, subject to employee consent.

35Discussion between employers and employees around fitness for work and adjustments

6 Discussion between employers and employees around fitness for work and adjustments

Key points• Discussions with employees around the fit note typically, but not always, involved line

managers, sometimes human resources managers and, in larger organisations, occupational health advisers.

• Negotiation of adjustments often took place on return to work rather than being planned in advance.

• For some employers, discussions about adjustments were reported to take place independently of the fit note and many employers were of the view that the fit note made little difference to these.

• Some employees believed that the fit note had empowered them in their negotiations over returning to work and that it had been instrumental in ensuring that changes were put in place rather than just agreed in principle.

In this chapter we describe the discussions which took place about adjustments to enable employees to return to work following receipt of a fit note. We include both employer and employee reports of these discussions. We look at what guides employers in their approaches and discussions about adjustments including whether the fit note was a key driver.

6.1 Discussions about adjustmentsWe asked employers and employees who was involved in discussions about the fit note and adjustments to facilitate a return to work. Employers were able to provide more detail than employees, since the former knew who would be involved ‘behind the scenes’ while employees were mainly aware of who they had contact with in the organisation and not necessarily who made the decisions in their own case.

Employers said that the most usual arrangement was for line managers to work with human resources, and sometimes with occupational health and Health and Safety advisers, to decide on appropriate adjustments. It was often reported that details of arrangements would largely be agreed between the line manager and the employee and that human resources would be involved to give official agreement and sometimes to provide advice, for example on the timing of amended hours and phased returns. Human resources would also be involved if the line manager could not offer adjustments, for example alternative duties, but these might be possible elsewhere within the organisation. A further reason for involving human resources, and potentially occupational health and equality experts, would be in cases which might come under the Disability Discrimination Act 1995. occupational health would generally not be involved in discussions about adjustments to deal with short-term absences, but for cases of long-term absence and, particularly, where capability might be an issue. However, many organisations with in-house occupational health involved them in all or most cases.


A human resources adviser in a local authority explained the arrangements within the organisation:

‘[who is involved]dependsupontheadaptations.Thelinemanagerhasgotaccesstohumanresourcesforadvice[and for]healthandsafety.It’sdowntothelinemanager.Theperipheralpeopleprovideadviceandsupport,wedon’tgooutanddoitforthem.Thelinemanagerownstheprocessbecausehehasthedirectrelationshipwiththeemployee,wedon’t.’

While it was common for discussions about adjustments to involve line managers, the employee and human resources, in a number of organisations, generally of larger size, the line manager was given principal responsibility for the process. The main explanation for this was the knowledge of line managers about what adjustments would be feasible.

‘It’ssomethingthattheyagreewiththeirmanager.Wealwaysencouragethemanagerandtheemployeetoworkoutwhat’sbestbecausewe’reatthebackofaprocess:theyhavetodeterminewhat’sbestforthem.’

Employees reported that their main contact over discussions about the fit note and adjustments was their line manager. This particularly applied to more straightforward cases involving simple adjustments, such as short-term amended hours. Arrangements were sometimes described as relatively informal without any obvious involvement of human resources or occupational health. It was common for employees to report that discussions with their line manager took place over the telephone, or at their ‘return to work’ interview, rather than through a face-to-face meeting pre-dating their return. In some cases, employees said that line managers visited them at home, combining a welfare call with discussions about return to work. Employees who had not succeeded in getting the changes they wanted to assist their return to work often reported that their line manager was their only contact. Employees who had more formal arrangements or whose cases were more complex, involving considerable adjustment in duties or working arrangements in the medium- and long-term, were more likely than others to report human resources involvement.

A small number of employers and employees said that discussions about adjustments did not involve line managers, but took place largely between themselves, human resources and, sometimes, occupational health. Employers explained this with reference to demands on the time of line managers and the need to standardise approaches. A representative of one company where decisions were made by human resources explained:

‘Thehumanresourcesadviserorhumanresourcesmanagerwillhaveownershipofthatissuebecausemanagers’qualityvariesandsomepeoplewilldoitverywellandsomenotsowell,sowe’vegottomakesurethereisalevelofconsistencyinhowwemanagethesesituations.’

Employees who said that occupational health was involved in discussions about their return to work were generally those in large organisations with in-house or retained services. Employees working for emergency services, including police and fire fighters were among those who reported having discussions with occupational health. Employees reported that discussions with occupational health were often by telephone rather than face-to-face. Employees also reported the involvement of occupational health, in discussions when they returned to work, about adaptations such as chairs and other workstation equipment.

We referred in Section 2.4 to the relationship between human resources and occupational health. The involvement of occupational health varied between organisations, with the service involved more usually in cases of longer-term absence and with a fit note stating ‘not fit for work’ and where a medical assessment was felt necessary. Human resources and occupational health did not always agree about appropriate action: one employer felt that its occupational health service (which was shared with another public sector organisation) suggested amended hours which differed from

37Discussion between employers and employees around fitness for work and adjustments

the organisation’s policy of not permitting part-time working. Another human resources director with outsourced occupational health stated that recommendations from occupational health were sometimes not practical, because they did not have sufficient understanding of the job.

One private sector organisation reported that responsibilities had changed, following the introduction of the fit note. While adjustments had previously been decided by occupational health, line managers were now being encouraged to make ‘reasonable adjustments’ where this was suggested by a fit note. However, this was not always successful, with one employee reporting that her line manager had not made the necessary adjustments to shift patterns. She complained that:

‘Thebacktoworkinterviewwasn’tdonethoroughlyandIwastoldIwouldgetabreakdownofwhatthephasedreturnwasgoingtobe,Iwouldsignacopyofthatandmydepartmentmanagerwouldsign,butthatneverhappened.Ourresourcedepartmentdidn’talwaysknowwhathoursIwassupposedtobeworking,Ihadtokeepconstantlygoingbacktobyteammanagersaying“Look,what’shappeningwiththis?”.Thewholethingwasn’thandledaseffectivelyasitcouldhavebeen.’

This employee explained these difficulties with reference to inexperience on the part of her line manager.

6.2 Drivers of discussions about adjustments: the role of the fit note

Employers stated that discussions about adjustments took place largely independently of the fit note and that the fit note was not a driver of the process. They reported that such discussions pre-dated the fit note and were usually initiated by trigger points of periods of absence (see Chapter 2). In addition, employers said that discussions about adjustments would often be sought with employees who were signed off as not fit for work (as they received relatively few notes indicating that an employee may be fit for work).

Employees had a different perspective from employers on the role of the fit note in facilitating adjustments – some felt it had helped. Employees were asked whether the fit note had made their employer more flexible in making changes following sickness absence, or whether changes would have been made in any case. One group of employees said that the changes would have happened in any case and that the fit note made little or no difference, while the other group felt that the fit note had resulted in change. There was no discernible difference in the circumstances of employees who fell into these two groups, by size of employer, sector or nature of their condition.

Employees who said that no change had resulted from the fit note cited evidence of such practice prior to its introduction or referred to policies relating to flexible working and adjustments. A number of employees expressed the view that a good manager would be willing to make adjustments to enable an employee to return to work and felt that the fit note had not affected this. An employee of a large private company who had a phased return to work following an operation explained:

‘Ijustgettheimpressionfrom[the company]thattheydoeverythingtheycantomakesuretheirpeoplearelookedafter,soregardlessofwhetheritwasafitnoteorsicknote,Ithinktheywouldhavetreatedmeexactlythesame.’

Some employees, while feeling that the fit note had not made a significant difference to their employer’s behaviour directly, believed that the fit note had given more power to the employee, which had then been instrumental in ensuring that changes were put in place rather than just agreed in principle. They, therefore, felt more confident in their negotiations with their employer.


This was a strong theme in responses from employees who felt that the fit note had made their employer more flexible in making changes.

Some employees expressed the view that the fit note had ended the assumption that an employee with a health condition cannot work and therefore opened up the possibility of negotiating adjustments with an employer. An employee with a pregnancy related condition which reduced her mobility explained:

‘Nowthere’sagreyareawherewecanthink,“Whatelsecanwedohere?”.Soitmightnotbeyournormaljob,itmightnotbeexactlythesame,itmightbeamendmentofhours.Sothisnewsystemhasinjectedthatgreyareawhereyoucandosomethingslightlydifferently.’

In her case, she had been able to negotiate working from home during the later stages of a difficult pregnancy.

A common theme among employees who felt that the fit note had made a difference was that it had empowered them to request adjustments. It was seen as harder for an employer to ignore an employee request when this was supported by a fit note. Some employees believed that the fit note had reduced their employer’s tendency to reject requests on grounds of organisational policy. For example, two employees had been able to agree reduced working hours even though part-time working was not usually allowed by their public sector employer. One of these employees said that, before the fit note, they would have assumed that part-time working would not have been a possibility. As we explained in Chapter 4, some employees had been encouraged to seek adjustments following discussions with their GP. An employee for a public sector organisation with a mild mental health condition explained:

‘AphasedreturntoworkstatementenabledtheGPtospellitouttotheemployerthatitwasn’tjustmydiscussionwiththem,itwasactuallysayingthatthedoctorhasspecifiedthisand,untilthistakesplaceIwillnotbereturningtowork.’

A number of other views were expressed by employees: some remarked that while their employer had been, in theory, more flexible as a result of the fit note, the changes were not effectively implemented. Another view was that the potential of the fit note to encourage employer flexibility was dependent on clarity in guidance from the GP. Some employees felt that their employer was more willing to be flexible if adjustments were clearly prescribed by the GP. This echoes the preferences expressed by some employers, reported earlier in this chapter.

A common theme in the employer interviews was that the main driver of discussions was to end the period of sickness absence through taking action such as adjustments or rating the individual as not capable of work and therefore terminating their employment. Discussions were sometimes informed by the Disability Discrimination Act 1995 where employers felt this provided the employee with protection from dismissal.

Although the fit note was not generally seen as a driver to discussions about adaptations, some employers said that it was. One reason given for this was that the fit note was evidence that the employee was able to do some kind of work, in cases where the employee was inclined to remain at home. However, we did not come across such cases in the employee interviews.

39Adjustments to enable return to work

7 Adjustments to enable return to work

Key points• Adjustments to hours were the most common adjustment in the organisations in the study

and, for employers, were the easiest to make. Other adjustments were to work equipment and alternative duties.

• Employees generally welcomed all types of adjustments.

• While employers said that making adjustments was usually worthwhile, they were not always possible and employees could be disappointed. Particular problems were reported with finding amended duties.

• Reduced hours, on a temporary basis, were seen as simple and effective and as helping to prevent early relapse which might lead to further sickness absence.

• The most successful phased returns were carefully planned and managed.

• Most adjustments made by employers to enable employees to return to work had cost implications. However, for employers these were highly variable and not often calculated. The main cost to employees of adjustments was the potential loss of pay resulting from altered hours, phased return, or other arrangement involving reduced hours. Employers varied in whether they made such reductions.

In this chapter we describe the adjustments made by employers, the ease or difficulty of making them and financial implications for employees and for employers. We explore how employees responded to the adjustments made and whether these enabled an earlier return to work. A strong theme in the employer interviews was the feasibility or otherwise of making adjustments. We present their views on the degree of ease or difficulty in making adjustments in specific instances and the consequences of the course of action taken in a particular case. The penultimate section provides examples of how adjustments worked in four organisations. The final section reports employers’ and employees’ views on how well adjustments worked.

7.1 Types of adjustmentsThe type of adjustments made to enable return to work depended on the workplace, the individuals’ occupation and other factors such as the implications for team members. Adjustments made also appeared to depend to some extent on the preferences of employees and on the willingness of employers to make changes.

7.1.1 Altered hours and phased returns Altered hours were reported as the most common adjustment made. This might take a number of forms, including a gradual increase in hours from very few to normal patterns, or a period of late arrival and early departure. This arrangement was typically made to avoid rush-hour periods, particularly in London. Altered hours were sometimes referred to as a phased return, by both employers and employees, where no changes were made other than hours of work. This may


result in confusion where a phased return involves no change in hours but amended duties or other temporary adjustment. The confusion may stem from the fact that the altered hours were often phased and may also stem from differences in the fit note terminology and that used in the workplace. In this section we have tried to distinguish between the two arrangements, referring to phased returns as involving a range of possible adjustments put in place to enable a gradual return to normal hours, duties and responsibilities.

From the employer perspective, reduced hours were particularly easy to make where employers already operated flexible working hours or where operations were continuous rather than 9-5. Flexibility or reduction in hours was also easiest where there was flexibility in roles, as in a hotel for example.

Reduced, or altered, hours were reported as easier to make than other adjustments. As the representative of a legal services firm explained:

‘It’seasiertodoreducedhoursthanmakephysicaladaptationsIfwetaketheroleofalawyer,it’sprobablyeasierforustosaytothemforashortperiodoftime“comeinforthreedaysaweekandthenfourdaysaweekandthenfivedaysaweek”.’

Therefore, a number of employees reported that they had been offered altered hours but still kept their same duties. While this was good for some employees, for others it meant trying to do all their work within a shorter number of hours and this was felt to be detrimental to recovery.

Altered hours were one of the most common adjustments reported by employees, who said these had been arranged following absence for a range of health conditions. These included road traffic injuries, operations, stress, arthritis and musculoskeletal problems. Altered hours were seen by employees as having two main objectives: to enable them to do some work when full-time hours, or commuting at peak times, would be too exhausting; and to acclimatise an individual to work following a period of absence. Such changes were welcomed by employees. Employers understood a ‘phased return’ through different duties or reduced hours, to work in somewhat different ways, with some regarding it as a tightly managed arrangement over a specified number of weeks, and others seeing it in more generic terms, as a period in which working hours are reduced, and built up. The pattern of a phased return to work was sometimes decided with the assistance of occupational health.

A common theme in interviews with employers was the need for altered hours and phased returns to be of fixed duration but some were willing to be flexible where an employee required a longer period of rehabilitation back to work, and where this was seen as beneficial in the longer term. An employer described the gradual return of an employee who had been in a road accident, from one day a week to five, over a period of three to four months, while another had agreed a phased return over 12 months.

However, these were exceptions, with employers generally unwilling to allow lengthy altered hours and phased returns, although a permanent reduction in hours, and pay, might be considered. One large manufacturing employer explained that if an employee’s need for altered hours or light duties was more than temporary, their capability for work would be investigated. Employees were also aware that such changes were generally temporary, made to enable a relatively rapid return to normal duties.

7.1.2 Workplace adaptations and amended dutiesEmployers reported physical aids and adaptations such as desk and chair adjustments, and modifications to IT equipment and software, as commonly made for all employees and not just those returning from sick leave. A number of employees also reported that such changes had been


made, although they were typically made after the individual had returned to work and rarely as a result of the fit note. These changes were generally reported as successful in dealing with conditions such as back pain. Other adaptations included allowing an employee to return to work with her leg in plaster, using a wheelchair to move around the office. The employer felt this adjustment had worked well, although the employee reported some problems such as difficulties with using the lavatories.

A common situation described by employers and employees was where an individual was able to work, but could not get to work because they could not drive or use public transport. Some employers had arranged transport for staff in these circumstances, but this was largely for more senior staff, with junior staff having to rely on family and friends to take them to work.

Inability to drive was also, not surprisingly, problematic where an employee’s job involved driving. This problem was reported, for example, by survey interviewers and sales representatives. While adjustments were often not possible, one employer had provided an employee with satellite navigation equipment to help reduce the degree of stress she experienced. Another employer provided satellite navigation equipment to enable an employee to drive at night following an eye operation.

Alternative duties were also arranged. These included, for example, taking an employee off telephone duties to administration work because of conditions such as stress, throat and posture difficulties. Employees with certain health conditions were also taken off safety critical work, for example, involving machinery, and assigned away from harsh or strenuous physical environments, for example, hotel kitchens and cold food processing areas. Employees of emergency services, such as police and fire fighters, could sometimes be offered less physically demanding duties, for example, doing community work. However, as we explain later (Section 7.2.1), employers sometimes had problems in arranging alternative duties.

Some employers gave particular consideration to adjustments for stress and mental health conditions, which were perceived as more difficult to manage (see Section 2.1). There were also indications from employee interviews that negotiations over such conditions could be lengthier than for other cases. Reduced hours were commonly arranged for employees with mental health conditions. An employer which engaged occupational health closely in decisions about adjustments described adjustments in cases of stress and mental health conditions as including restriction to office duties, rather than travel, reduced working hours and assignment to projects without high pressure or tight deadlines. Another employer, which itself provided services for people with mental health conditions, offered a wide range of phased returns and adjustments for staff returning to work following a period of poor mental health. These included allowing staff taking morning medication to start later in the day and adjustment of tasks to avoid exposure to trauma. An example of an adjustment reported by an employee was assignment of a policy analyst to a discrete project, to enable gradual build up of skills and confidence.

7.2 The response of employees to adjustmentsEmployers said that employees generally responded positively to the offer of adjustments aimed at getting them back to work. This is to be expected, given that, as we described (Section 4.1.2), in many cases employees take the lead in suggesting adjustments. Therefore, we found many employers keen to find ways in which they could help employees return to work before their health was fully restored and welcoming adjustments. Particularly welcome were phased returns, which enabled employees to build up their strength and to become reacquainted with work routines and relationships, and adjustments which addressed work-related conditions such as back pain.


Employers reported that some employees were also willing to return to work without adjustments and sometimes needed persuading to consider these. As the in-house occupational health adviser for a large private sector employer explained:

‘Someofthemwillthink,“Oh,Icanjustcomebacktowork”,butdependingonwhathasbeenwrongwiththem,alotofthemwillsay“Actually,youwereright,Iwouldneverhavebeenfittocomebackfulltime”.’

A number of employees confirmed that they had underestimated the need for adjustments to enable them to return to work. Some felt they had returned to work too soon (see Chapter 8). Another employer, in the public sector, also commented on employees’ concern to return to work, with or without adjustments:

‘Ithinkwehavequiteahighlevelofemployeeengagementhere.SoI’moftenbeatingthemoffsaying“Youreallyneedtobestableonyourlegsbeforeyoucanattempttocomeback”.’

A number of other employers also commented on the high level of employee commitment and their keenness to return to work at the earliest opportunity, although in some cases they recognised that this was driven by the absence of sick pay. As we explain later, employees referred to pay as a factor in their desire to return to work.

We described earlier how the fit note was seen by some employees as empowering them to negotiate a return to work. The fit note was seen by some employers as raising employee expectations that adjustments would be made to enable them to return to work. Expectations were reported to be highest among those without sick pay or whose sick pay entitlement was running out. Therefore, some employers felt that, following the introduction of the fit note, they were having to do more to manage employee expectations.

Employers reported resistance from some employees to adjustments to enable an earlier return to work and believed that some employees prefer to stay on sick leave or even to have their contract terminated. One view was that some employees are concerned about loss of status resulting from alternative duties. We found little evidence from our interviews with employees to support this assessment, although some employees did accept their GP’s assessment that they were not fit for work, without discussing adjustments, despite adjustments having been made in similar cases.

7.2.1 Instances where adjustments were not possibleEmployers’ view was that it was generally worth making adjustments where possible because of the costs of absence and of replacing employees who could not carry out their usual duties. In some cases, adjustments had been difficult to make or had not worked out and in others, adjustments had not been possible. Cases where employees’ requests for adjustments had been declined largely involved amended duties rather than altered hours. One employee of a large public sector organisation complained that the employer did not offer alternative duties when he was diagnosed with repetitive strain injury:

‘It’sfrustratingbecauseit’samassivedepartment.IthoughttheycouldputmesomewherethatIcoulddoafulljobandbecompletelycompetentinthatjob,andIwasjustforcedtobecomealiar[by telling the GP his condition had improved]inordertokeepfoodonthetable.’

From the employers’ perspective, the relative ease or difficulty with which adjustments could be made appeared to depend on a range of factors. These included flexibility in roles across the organisation, the costs of adaptations and adjustments, employer and employee willingness over alternative duties and the medical condition itself. Employers reported four main difficulties with making adjustments:


• the availability of alternative work within the organisation;

• the suitability of an individual for alternative duties;

• the need to work set hours;

• concerns about whether alternative duties would assist recovery or be detrimental to health.

Some difficulties were reported with reduced hours, for example in an orchestra where a musician was required to attend all rehearsals for a performance, in legal practice on cases that involved intense negotiations and fixed deadlines and in areas of social work with a case load system.

A common problem reported by employers was in finding alternative work for employees who are not able to carry out their normal duties. The most usual adaptation requested, either by the GP or the employee themselves, was for ‘light duties’ and sometimes for work with no public contact.

Care homes, hospitals and emergency services and an orchestra were among the employers who said that light duties were difficult to organise or that there was a shortage of work. The manager of a care home talked of the shortage of duties which could be described as ‘light’ in that particular workplace:

‘Becauseofthisenvironment,there’snothingelsethatpeoplecandothatminimisesthephysicalsideofthework.Youcan’tsendthemtothelaundrybecausethat’sveryphysical.Youcan’tputtheminthekitchenbecausetheminutetheybendoverasinkthey’vegotabadback.Yougivethemcleaning,they’vegottopushaHooveraroundandwhateveryoudoactuallythereisn’tanysuchthingaslightwork.’

Typical alternative duties for fire fighters involved community safety work, but its availability was limited. In emergency services, employees would have to agree to coming off shift work, as well as to alternative duties, and this was sometimes problematic for employees with other commitments, for example childcare. Problems were reported where individuals in jobs which required them to drive could not do so and where alternative duties were not available. Alternative duties were sometimes seen as inappropriate, for example, an orchestra manager remarked

‘Amendedduties?Well,youjustwantthemtoplaytheirviolinreally.Imeanthereisnotalottheycandothatisdifferenttothat...Inotherorchestrastheyhavehadahappycoincidenceofaplayerwhohasneededtostopplayinginthelibraryforinstance.Thatmightbesomethingyoucansortofputtogetherifitissuitableanditisintheplayer’sinterest.Butyoucouldn’tjuststicksomebodyextrainthelibraryorstuffingenvelopes.Thatdoesn’treallywork.’

Another factor leading to difficulty arranging alternative duties was current cut backs and job reduction programmes.

Difficulties in finding alternative duties resulted from employees’ suitability as well as the availability of positions. These included:

• a reluctance to place professional, highly skilled and higher paid staff on routine duties, particularly for anything longer than a few weeks;

• problems where employees did not have the skill base for other duties to be feasible;

• difficulty of finding roles for employees with limited English.

The possibility of finding alternative duties was not necessarily related to workplace size. For example, a small farm employing 95 people was able to find alternative duties for staff with minor injuries, such as cuts, muscle tears and sunburn which made fruit picking difficult. This was possible


because each employee carried out up to 12 different jobs during the working day, involving different physical demands. The employer also arranged for work involving limited physical effort, such as loading wire onto a machine to be brought forward from when it was usually done, in the autumn, to summer months as it was not dependent on the season. A further factor which inclined the employer to find alternative duties was, in this case, the lack of sick pay.

Some employers felt constrained in the adaptations they could offer by concerns that they might damage an employee’s health. The possibility of litigation was a particular concern, as was placing excessive pressure on employees with stress or mental health conditions. Difficulty was also reported where the relationship between the employer and employee had broken down and where disciplinary and grievance procedures placed restrictions on duties and reporting arrangements.

7.3 Financial and other implications of adjustments for employees and employers

7.3.1 Costs to employersMost adjustments made by employers to enable employees to return to work had cost implications. However, these were highly variable and not often calculated.

In terms of expenditure, workplace adaptations were the most visible costly forms of adjustment and employers reported that these sometimes involved considerable expenditure. Specialist equipment, for example adapted suits for fire fighters, was reported to be very costly. However, more routine items such as chairs, for employees with back problems, were also reported to be costly. It was common for employers to weigh up the costs and benefits of making adaptations through purchase of new equipment. A large employer in the professional and business services sector described the considerations which informed this process:

‘Iftheadaptationisaoneweekadaptationandwhatthedoctorissuggestingisforustopurchaseequipmentthat’sgoingtobeverycostly,thenIdon’tthinkthat’saproportionateresponse.TherewillbeoccasionswhenI’drathertheindividualjustdidn’tcomeinforanotherweekratherthanspendingtwograndonapieceofequipmentwhichisgoingtoberedundantinaweek.’

Employers were also concerned that adaptations involving financial outlay were appropriate and likely to be effective. As another employer explained:

‘Iwouldwantouroccupationalhealthteamtocomeandsay,“that’stherightequipment,thatwillactuallyhelp”becausewhatemployeestendtodoisthinkthatspendingmoneywillresolveaparticularissueandbeforeyouknowit,you’vekittedoutadeskwith300piecesofequipmentthatmakesnodifference.Sowewouldtakeasensibleviewonit.’

Other costs incurred by adjustments including reduced productivity of employees on alternative duties and the need, in some cases, for additional cover. The net costs in these cases depended on sick pay entitlement and whether pay was reduced due to fewer hours or different tasks (see later).

7.3.2 Costs to employeesThe main cost to employees of adjustments was the potential loss of pay resulting from altered hours, phased return, or other arrangement involving reduced hours. A common practice was for


employees on temporarily reduced hours, to have no reduction in pay. This was sometimes included in organisations’ sickness absence policies (see Section 2.3). The period of protected pay varied, and could be as short as one or two weeks. One observation of employers was that a period of protected pay helps to get employees back to work and makes their permanent return more likely, while reduction in pay would act as a disincentive. However, not all employers protected pay, and, in some cases, employees working reduced hours automatically found their pay reduced accordingly. As some employers mentioned, this could act as a disincentive to working reduced hours, where the alternative was remaining absent and receiving OSP.

Employees facing a temporary cut in pay through working altered hours typically used their annual leave. This arrangement was reported by both employers and by employees. As described above, another practice, found in workplaces with occupational sick pay, was to count the un-worked hours as sickness absence. Under this arrangement, employees who had exhausted their sick pay entitlement would be paid for the hours they worked only.

Employees on alternative duties usually continued to be paid their usual salary. However, employees whose pay included shift premiums could lose these if their alternative duties involved regular hours: one employee, a police officer, estimated that this had amounted to a loss of £600 over a two month period.

In organisations with automatic triggers for action on sickness absence, a second issue for employees was the whether the period of reduced hours was treated as sickness absence or not. This varied. Treating employees as not absent increased the incentive to return.

7.4 The response of colleaguesFor employees, one of the most positive aspects of the return to work following sickness absence was the response of colleagues. Employees found that colleagues were welcoming, were pleased to see them and were understanding about their health condition and the limitations that these might place on their hours and duties. Some said their colleagues had covered for them in their absence and that even when they returned on reduced hours, this resulted in a reduction in colleagues’ workload. In one case, colleagues were found to benefit from a police officer’s restriction to clerical duties, since he was able to do all their paperwork.

While employers sometimes said they arranged additional staffing to reduce the impact on colleagues of reduced hours and amended duties, this was reported as rare by employees. Some employees felt that there was a relationship of ‘give and take’ with colleagues and that it was common for individuals to cover during periods of absence for reasons other than sick leave or phased returns and adjusted duties. One view expressed by employers was that the fit note increased the acceptability to colleagues of an employee’s reduced hours or altered duties, since the arrangement had been sanctioned by a medical practitioner.

Many employees commented on the extent of support provided by their colleagues and the help they gave on their return to work. A common theme in the employee interviews was how colleagues had to carry out duties which they could not, for example lifting, answering telephones and generally having to work harder. Respondents were very aware of these implications of adjustments to their hours and duties on their colleagues. Two employees who had a phased return to work, one following a trapped nerve in her neck and other for an operation spoke about the support they had received from colleagues:


‘MyphonewentthroughtomycolleaguewhoIsitnexttoandshewashappytodomyphone.Ithink[this was]becauseshehadseenmeinpainmorethananybody.TheoneswhoyouactuallyworkwithhaveseenyougothroughitandsotheyknewthatIwasn’tputtingiton.Theyknewtherewasaproblemandtheywerereallykindandabsolutelyfine.’

‘Mostpeoplewereverykindwithmeandwarnedmetobecarefulaboutthecomingbackthingbecause,onceyou’reback,you’rebackandpeopleexpectyoutobetheredaytodayanddoeverythingthatyoudidbefore.Itwasnicetotakeiteasyandnotoverstretch,everybodywaslikethat’.

Some employees commented that their relationship with their colleagues should not have been tested in this way, and that the employer should have provided more adequate cover while they were working reduced hours, a phased return or on alternative duties. It was also apparent that some employees returning from sickness absence were aware that their colleagues had taken on additional work and were concerned that this should not continue. Employees on a phased return could feel guilty that colleagues were having to work harder. One response was to work more hours than had been agreed to minimise the continuing impact on colleagues.

Not all employees reported positive responses from colleagues. Some employees reported pressure to carry out restricted tasks or to work harder than they felt was advisable for their health. Conversely, some colleagues could be over-protective when an employee was concerned to be treated as normal. One employee, with multiple sclerosis, who arranged a permanent reduction in hours, experienced resentment from colleagues who wanted to work part-time but had not been allowed.

Employers also reported that adjustments sometimes raised issues of fairness. One employer reported that permission to work at home, for medical reasons, could lead to resentment among staff who were not allowed this arrangement. Another employer explained how reducing the hours of an employee was seen to affect the morale of colleagues, even though this had not increased their own workload. A team manager explained how a member of staff returned to work as a telephone operator but could not talk, so was put on light duties. The team were reported to react unsympathetically, leading to a decision to move the member of staff to a different department:

‘Theyjustseetheindividualascominginwhenwedoa12-hourshift,doinglightdutiesandthengoinghome,soitwashavinganeffectonthem.Itwasaffectingtheteammorale.Movingherwasjustbetterfortheteam.Theyjustdidn’tlikeseeingtheindividualcominginandgoing,theythought[she was]gettingofflightly,butshegenuinelyhadnovoice,shecouldn’tspeak.’

Another employer expressed the view that, if colleagues complain that reduced hours were unfair, their line manager should communicate the reasons for this adjustment.


7.5 Examples of adjustmentsThis section provides examples of how adjustments worked in practice in four of the participant organisations.

Case study 1: Fruit farm Workforce: 95 people employed all year round and 150 additional seasonal staff. Many employees are migrants from Eastern Europe.

Sick pay arrangements: the company does not offer Occupational Sick Pay (OSP) to its operational staff, who form the majority of the workforce.

Before the introduction of the fit note, employees who were not able to carry out their normal duties were given alternative tasks, but the manager of the farm believes that the fit note has made the process more formal. Having a GP’s recommendation for adjustments has also made it easier to off-set potential resentment from other staff where a colleague is assigned lighter duties.

Around 50 per cent of the fit notes received by the farm have stated that the employee may be fit for work which the employer explains with reference to the absence of occupational sick pay and employees’ keenness to continue working.

Alternative duties are offered to workers who are unable to pick fruit because of minor injuries, such as cuts, muscle tears and sunburn. This is possible because each employee carries out up to 12 different jobs during the working day, involving different physical demands. The employer also arranges for work such as loading wire onto a machine to be brought forward from the autumn to summer months, which is a task involving limited physical effort.

Case study 2: Domiciliary care companyWorkforce: 90 people.

Sick pay arrangements: the company does not offer OSP.

The company has experienced difficulty making adjustments for employees with a fit note stating ‘may be fit for work’. Assigning an employee to a ‘double run’ (where two care workers work alongside each other, allocating duties based on capability) is the main adjustment. Other adjustments were seen as difficult to make and the employer expressed concern that, without clear guidance from a GP, working could exacerbate the individual’s health problems.

Employees expressed their keenness to work where possible, with adjustments, since they could not afford to live on Statutory Sick Pay (SSP). However, adjustments did not always work well. An employee recommended by her GP to carry out ‘light duties’ following an operation described how the ‘double run’ arrangement had not worked well for her. Despite her manager agreeing to place her on double runs, her rota also included single runs. Moreover, her team leader questioned whether she should continue in the job if she could not work as normal. She reported the lack of the promised adjustments to head office human resources. This resulted in rapid and effective implementation of the agreed adjustments.


Case study 3: Food processing companyWorkforce: 250 employees, the majority of whom are in semi-skilled manual roles, including filleting and packing fish.

Sick pay arrangements: The company provides OSP for a limited period, with length of service requirements.

Adjustments were considered prior to the introduction of the fit note and managers felt that their practice had not changed significantly. However, they believe that the fit note has resulted in improved guidance from GPs about the condition, alternative duties and adjustments and greater openness among employees who have conditions which mean they cannot work in a food environment. This has reduced anxiety among managers that returning to work might be bad for the employee or for the business. It was also believed, as in case study 1, that having a GP’s recommendation for adjustments makes it easier to off-set potential resentment from other staff where a colleague is assigned lighter duties.

Assignment to office-based duties were seen as sometimes problematic, where staff had weak English language skills or could access confidential documents. Therefore, sometimes minor injuries such as a cut finger could mean that alternative duties were not offered.

• An office based employee with a fit note suggesting amended hours was allowed to work part-time, and also do some work from home, following a virus and chest infection. The GP had suggested signing this employee off work in order to recover fully, but the employee felt they could not take the time off.

• A production worker was moved to administrative duties following a leg injury. Motivated by wanting to return to work for financial reasons, this employee found it useful to learn about the stock-taking and ordering process to which he had been assigned.

Case study 4: Charity Workforce: 750 people providing domiciliary care to people with mental health problems.

Sick pay arrangements: OSP is provided, subject to length of service.

The head of human resources believes that, while they would previously have offered adjustments, the fit note has given them more guidance from GPs on what type of adjustment could be helpful. With many employees having mental health conditions, the employer found a phased return, with reduced hours and increased support, a useful option offered by the fit note.

Employees reported a range of adjustments to enable them to return to work with a fit note with most, not all, finding these had worked well:

• An administrator with stress felt she had benefited from a phased return, combining reduced hours and gradual increase in responsibility, during which time she had regular mentoring sessions with her line manager.

• A support worker also had a phased return following an episode of acute osteoarthritis. This employee felt that the fit note had made the employer more amenable to making adjustments and had made them more confident about asking for these.

• Another support worker also believed that it had been easier to agree a phased return following absence for back pain, because his GP had suggested phased return with amended duties.

• A hospital-based rehabilitation worker welcomed returning to work on amended duties but felt that, despite the fit note, team members expected him to perform as normal and that his reduced duties placed other employees under stress.


7.6 Whether adjustments had worked Adjustments were generally found to work well from the employer perspective. Amended hours were seen as particularly successful because they involved minimal additional administration and management or additional costs, for example, purchase of new equipment. Amended hours and phased returns were seen by some employers as particularly helpful in assisting committed employees to return to work sooner and as helping to ensure that returning to work did not have a detrimental effect on employees’ health. Employers also reported that the outcomes of amended hours and phased returns were particularly good where absence had been long and where the employee needed gradual introduction to work demands.

As we noted earlier, some employers felt that amended hours and phased returns have to be short and sharp. However, other employers gave examples of very gradual return to normal hours. These were usually cases involving valued employees or those with particular health issues. One employer gave the example of an employee who had returned on a very gradual build-up of hours following a heart by-pass operation and another described a very slow return arranged for a highly valued member of staff.

A number of employees said that the adjustments arranged with their employer had worked particularly well for them.

These employees had a range of conditions, including operations, broken limbs, car accidents, ulcers, back injuries and stress/depression. Adjustments in all of these cases involved amended hours, although some also involved phased returns to work and alternative duties. An analysis of the features of these nine cases suggests that a number of factors lead to a successful outcome for employees:

• having clear arrangements with the employer, which could incorporate guidance from the GP;

• a return to work plan which contained details of their hours and duties over the phased period;

• close supervision of the individual’s workload and hours so that they were reminded to go home rather than overstay their agreed hours;

• regular ‘catch-up’ sessions with the line manager to check that the employee was coping with the adjustments or whether further changes were required.

Careful planning of duties to build up strength was seen as particularly helpful, as an employee working for a charity explained:

‘ThefirstweekIwasherewasmoreorlessintheoffice,althoughwedon’thaveofficebasedstaff,thebosshadmedoingsomeaudits,shehadmereadinguponsomenewpolicies.ThenthesecondweekIstarteddoingclients.’

Close supervision of workload was valued by employees who felt they might otherwise have over-exerted themselves. A feature found in cases seen by employees as successful was regular catch-up sessions. As an employee for a large private sector employer, who returned to work following an operation explained:

‘Iwasspeakingto[the occupational health adviser]everytwoweeks,we’dre-visittheplan,we’dmakeaplanforthenexttwoweeks.’

Employees found this degree of vigilance reassuring and helpful in planning their own return to normal hours and duties.


A number of employees said that changes had not been made to accommodate their health condition, although they had fit notes and had expected that their recommendations would be followed. Therefore, some employees were working in cold environments or with food while sick, although they had a fit note suggesting alternative duties. A number of employees explained that adjustments had been agreed but were not implemented. A care home employee who was recommended to carry out ‘light duties’ following a hysterectomy found her team leader expected her to lift elderly patients, despite obtaining further fit notes clarifying the need for adjustments. This employee described what happened:

‘Ispoketothebossandshesaid“OhGod,Ohb****yh***,wewillhavetochangeit”andwasn’tveryhappyaboutit.Thentheysentanotherrosterthroughthefollowingweekanditwasthesame’.

Other cases where employees felt adjustments had not worked included:

• amended duties were arranged for an employee returning after an episode of pleurisy, but were not implemented by the line manager because the department was short-staffed;

• adjusted duties were agreed for an employee with gout, but the office was small and colleagues frequently forgot that his duties were different;

• an employee who was recommended to have reduced hours following post-natal depression was offered the same hours but reduced responsibility.

These cases highlight a number of problems with the implementation of adjustments. These include the need to ensure that line managers follow the agreed changes and that attention is given to how team members’ duties might be changed to accommodate employees with particular health conditions.

51The fit note and an early return to work

8 The fit note and an early return to work

Key points• For employers, the benefits of an earlier return to work were reduced absence costs.

• For some employees an earlier return to work meant avoiding loss of pay or disciplinary action.

• Sick leave was seen by employees as bad for their job security and career prospects, especially with the economic downturn at the time of the study.

• Employees commonly referred to having been bored at home and missing being at work but in some cases employees felt they had returned to work too soon.

This chapter examines how the fit note affected employees’ return to work and the consequences of return, for example on employee health and well-being. The evidence is drawn from the reports of specific cases of absence and the use of the fit note.

8.1 The role of the fit note in assisting a return to workEmployers reported that one effect of the fit note was to enable an earlier return to work for some employees. Some employers had found that it opened up discussions about adjustments. However, as we noted earlier, many employers said they had not received fit notes suggesting adjustments and one view was that the opportunity to enable an earlier return was sometimes missed.

Of the adjustments options listed on the fit note, a phased return was seen by some employers and employees as most likely to result in an earlier return to work, although this often involved adjusted hours rather than other changes designed to facilitate a return to work. Other adjustments such as adaptations, while sometimes agreed in advance, were frequently made once the employee had actually returned. As well as enabling an earlier return to work, altered hours and phased returns were seen as helping to prevent an early relapse in health which can occur when an employee returns to normal hours and duties too quickly. One employer gave the example of an employee who had been off work with work-related stress returning to a discrete project with a flexible deadline, which enabled them to build up their hours at their own pace. The success of this arrangement in enabling an earlier return to work was confirmed by the employee.

Some employees felt that the fit note empowered them in their negotiations with employers (see earlier). There was a view that , while the fit note was not in itself responsible for an earlier return, it led to a better return to work, which had made the transition back to normal duties easier or had helped in the employee’s recovery.

Employers gave a number of examples of where employees were able to return earlier than they might otherwise have done because of adjustments. One employer gave the example of an employee with a tendon problem who was able to return by working alternative days. Examples given by another employer included an employee who returned to work with a leg in plaster who used a wheelchair to perform her normal duties and another with voice problems who was given alternative duties to telephone work.


Early returns to work were not always successful from the employer’s point of view, typically where employees were keen to return but could not perform effectively. These included employees without sick pay who wanted to work their normal hours, and some who did not want to be away from work. The manager of an orchestra explained:

‘Ratherthanussaying“youhavetocomebacktoworkonaphasedreturn”wewouldsay“look,don’tbeinsuchahurrybecausethereisnohurry,you’llbeexhausted,yourstitcheswillcomeundoneagain...”.Thelastthingyouneedissomebodyjustaboutrecoveredcomingbackandsettingthemselvesbackanothermonth.’

Similarly, early returns were not always seen as beneficial by employees. Some had used the fit note to achieve an earlier return to work, but felt in retrospect that this had been detrimental to their health. A manager working for a pharmaceutical company who had arranged to work from home following an operation explained how:

‘IknewIwantedtogetworkdoneandIdidtoomuch....NowI’vegottogoandhavesomecorrectivesurgery,additionalsurgery...Ihadthatflexibilitytogoandarguemycaseandsay“Iwanttodothis”.’

While he felt that he would have done the same before the fit note, he believed that it could encourage employees to return earlier:

‘…andthere’llbeotherpeoplefoolishlikemewhomakethewrongdecisionsanddotoomuch.’

8.2 Benefits of an earlier return to work Employees were motivated by a number of factors to return to work earlier than they might otherwise have done. Some of the main motivating factors were negative and related to concerns about the consequences of absence, while others relate to the benefits of working over inactivity and to the role of work in people’s lives.

We described earlier how employee pay was affected by both sickness absence and by altered hours and phased returns to work. Therefore, some employees were keen to return to work earlier in order to be paid. In Chapter 2 we also described employers’ policies on sickness absence and the system of ‘trigger points’ in some organisations for investigating individual sickness absence rates. A number of employees said that they returned earlier to work principally from concern at their current ‘Bradford score’ or because they were close to, or already having, disciplinary action for sickness absence. Therefore, an earlier return was of benefit in forestalling such action. We found some cases where employees were keen to return early through a fit note while still clearly unwell, sometimes taking medication to relieve pain. An employee for a large public sector organisation explained the reasons why he had gone back to work despite having Repetitive Strain Injury:

‘IfeltalotofpressuretogetbacktoworkandIknewtheywerelookingatwhethertheyweregoingtosackme.Icouldn’tgothroughallthat,Ihadatwo-weekoldbabyinthehouse.’

Concerns that absence might affect career progression were also voiced by some employees. For example, an employee who broke a wrist during a session with her personal trainer explained that she had ‘pushed’ her GP to request an earlier return because:

‘Iwouldliketogetpromotedtoseniormanager,soitwasthatwhichwasmakingmethinkthewayIdid.’

Some employees returning to work earlier felt they needed to demonstrate their commitment to work. Other employees were concerned at their job security, particularly in workplaces where

53The fit note and an early return to work

redundancies were being made. An employee of a law firm who returned to work despite in pain from a trapped nerve in her neck, explained:

‘Ifeltcompletelyunderpressurebecauseoftherecession.Mypersonalcircumstancesaresuchthatmysalaryisthemainsalaryandmyhusband’sjob,becauseoftherecession,hasreducedtopart-timehours.SoIfeltveryunderpressuretobeherephysically.’

Another employee, for a food processing company, was concerned that a prolonged absence for a back problem would result in dismissal.

An earlier return, through reduced hours or adjusted duties was also seen to have the benefit of proving capability. One employee, a fire fighter who had been injured at work, saw the opportunity to work in a different role as helping to protect him from dismissal on grounds of capability.

8.2.1 The effect on work of an earlier returnThe benefits of an earlier return identified by employers largely concerned benefits to work and productivity. Reduced hours were seen as better than no hours, and working at home seen as preferable to no work at all. An early return was also seen, by both employers and by employees, to reduce the danger of termination of an individual’s contract which can result from prolonged sickness absence and withdrawal of contact. Keeping an individual in work was seen as particularly important in cases of stress and anxiety, as a human resources adviser explained:

‘Comingbackstraightaway,toreallylotsofwork,full-time,thatmightbetoomuchforpeopleandthenthatmightmakethemgooffagain.’

Sometimes there were reservations about whether an early return was useful from the employers’ point of view: one employer expressed the view that adjustments result in employees returning earlier to work, but are only worthwhile for the employer if they return to their own job. An occupational health specialist explained:

‘Iftheycan’tdosomepartoftheirownjob,weprobablydon’treallywantthembackatwork.Wedon’tgivepeoplelightdutiesjustforthesakeofgettingthembacktowork.Weliketohaveaplaninplaceforgettingthembackintotheirownjob.’

However, a different perspective was given by some employees who felt they had benefited from carrying out other duties: an employee of a food processing company said that performing alternative duties, following an early return with a leg in plaster, had given him an insight into the non-production side of operations.

One view expressed by employers was that making adjustments has wider benefits for employment relations and communicates to employees the organisation’s supportive culture. Making adjustments was also seen as a way of communicating organisational change around sickness absence. The head of human resources explained:

‘Itdoeshelptodemonstrateinavisiblewaytopeoplethat,ifwesaythatwearegoingtobeasupportiveculture,weare.Ithelpsdrivesomeoftheculturechangeprogrammethatwearelookingtoembedaswell.’

Employers also felt it advisable to show compliance with the Disability Discrimination Act 1995.

8.2.2 The effects on health and well-being of an earlier returnSome employees said that an earlier return to work had benefits for their health. These included employees with mild mental health problems who felt that working reduced their levels of anxiety


and employees recuperating from surgery or physical illness who were building up their physical strength and stamina. Some employees recovering from injuries found that the activity of work had physiotherapeutic effects. Employees who were concerned about their health found that work was a helpful distraction. An employee who had suffered kidney failure explained:

‘Youdon’twanttogodownthatroadwhereeverythingcentresaroundyourhealth.Youwanttohavealifeapartfromthatandthatisthegoodthingaboutgoingbacktowork,thatyouaredealingwithpeopleandyouhavearoutinetoyourlifeagain.’

Another employee, who had been treated for cancer similarly explained: ‘Iwasdesperatetogetbacktosomesortofnormality’.

The main benefits for employees of an earlier return to work were to their well-being more generally, rather than to their health. Therefore, a very common theme in the employee interviews was boredom at being off work. Employees said they missed work for the contact with colleagues, with clients and some for the work itself. A number of respondents referred to the mental lethargy induced by watching daytime television. An employee with mobility problems caused by pregnancy commented:

‘Iwouldmuchratherbeabletodothis[work from home]thanjustbesignedoffandhavetowatchJeremyKyleandFlogItalldaylong....Formeitwasjustaboutbeingabletodosomethingandstillusemybrain.’

For some, working brought benefits such as self-fulfilment and social contact. As two employees, both working for charities, explained:

‘Iwasactuallykeentoreturntowork,plusaswell,thecontactsthatI’vemadethroughmyjob,Iwantedtoseehowpeopleweredoing….Soitwasapersonalthing,personalfulfilmentmorethananything.’

‘Iwasquitepassionateaboutthejob...soitwasreallynicebeingbackbeingabletohelppeople....IhaveworkedsinceIwas13soIamjustnotsomeonewholikestositaround.’

Some employers made similar observations on the benefits of working over inactivity, referring particularly to mental health. However, as discussed earlier, some employers were concerned that employees sometimes returned to work before their health warranted and that an early return might be bad for their recovery. Likewise, employees who returned to work early, with or without a fit note reported pain and exhaustion. These included a respondent who returned to work only days after a shoulder operation and another who returned to work in a wheelchair with a leg in plaster. Both felt that their early return had delayed their physical recovery and that, in retrospect, an early return had been a mistake. Other employees talked of the difficulty of working while taking strong pain killers, which included concerns that they were incoherent in meetings.

55Employers’ views about the effect of the fit note

9 Employers’ views about the effect of the fit note

Key points• Prior to the introduction of the fit note, some employers were positive about the change.

Some employers retained or developed this positive view and believed the fit note had had a positive impact. Others felt it had had little or no impact, but often remained positive about the idea, if not the practice.

• Some employers believed that the fit note had influenced sickness absence rates and durations, leading to greater consideration of adjustments, increased flexibility over adjustments, more adjustments being made, employees thinking more about returning and relapse being less common.

• Employers who thought that the fit note had not influenced sickness absence thought this was the case because they had previously made adjustments, employees had always been keen to return to work quickly, the fit note either did not suggest adjustments or useful information or it was treated as a sick note by employees or line managers. These views did not always correspond with the detailed descriptions of how fit notes had been used.

• Some employers believed the fit note had improved how they managed sickness absence and that managers or employees were better informed on appropriate action. Others felt it had made managing sickness absence more difficult, because it proposed inappropriate adjustments or raised employees’ expectations about adjustments.

• The fit note was believed by some employers to have altered employers’ and employees’ attitudes to sickness absence.

• Some employers believed that information flows with GPs had improved due to the fit note.

The previous chapters have examined, in detail, actions in response to the fit note and how it was used. This provided extensive information on how the fit note was working.

Employers were asked for their views on the effect of the fit note on a range of factors, including sickness absence, management of sickness absence, attitudes towards sickness absence and relations with GPs. These views are reported in Section 9.1.1. As we shall see, their views did not always coincide with their reports of their responses to individual fit notes (reported in Chapters 7 and 8). Recognising this divergence is important in assessing the fit note itself, as employers’ stated views about its influence suggested less effect than did the descriptions of how the fit note was used. Understanding areas of divergence is also important for improving the effectiveness of the fit note, as employer responses to fit note policy will be partly conditioned by their views.

Finally, employers were asked for suggestions for improving the fit note and about other assistance that would be helpful for reducing sickness absence. These are reported in Section 9.2.

9.1 Views on the effect of the fit note As explained in Chapter 1, the fit note was aimed at enabling an earlier return to work through facilitating adjustments at workplace level. Here we consider employers’ views on the effect of the


fit note on sickness absence and on the management of sickness absence. We also consider any other impacts, for example on perceived attitudes or organisational culture.

Prior to its introduction, some employers were positive about the fit note, although this was not the case across the board. Some employers retained or developed this positive view and believed the fit note had had a positive impact. Others felt it had had little or no impact. The following quotes give a feel for the range of views:

‘Thefitnote’sadvantagesarethatitdoesgive,Isuppose,theGPsthechancetosaywhattheyfeel.[Previously],ifsomeoneiseitherwellortheyarenot,thechancesaretheyarenotgoingtocomebacktowork.Whereas,thisway,ifyoucanatleastoffersomeadaptationtogetpeoplebacktoworkthenIthinkthat’sagoodthing.’

Some employers said that they saw no advantages of the fit note, that it had made no difference. However, one advantage was seen in its name:

‘Ithinkjustchangingthenameinitselfwasahugeadvantage,yeah.BecauseIthinkit’ssayingtopeople“you’refitforwork”ratherthanpeopleplayingon“I’msick”.SoIthinkputtingthatchangeanddifferentspinonitwasagoodthingfromthatpointofviewbutIdon’tknow,Ican’tsaythatI’veseenthatmuchdifferenceapartfromthat.’

Others preferred the sick note:

‘Ipreferthesicknote,becausedoctors’recommendationsarenotnecessarilyfeasibleandcanresultinextracosts.’

Others felt that the fit note was not tackling their main concerns, which were short-term sickness:

‘Inaway,probablythegreaterproportionofsicknessthatanyonewouldbeconcernedaboutwouldalwaysbetheperiodbeforeyougettothefitnotethatyoumustbetheoddday,theplayerwhoneverseemstobeabletocomeinonaSundayoryouknow,theywouldn’tneedafitnote,theyself-certificateornothing.Itisalwaysthoseshorterperiodsthatyoumightraisetheoddquestion.’

Views on the effect of the fit note on sickness absence, the management of sickness absence, attitudes and information flows with doctors are described below. We have tried to avoid repeating the issues discussed in previous chapters.

9.1.1 Employers’ views on the effect of the fit note on sickness absence

ReasonsemployersbelievedthefitnotehadhadapositiveeffectA range of different types of employers believed the fit note had had a positive effect. This included organisations which had previously made adjustments, as well as those which had not and included organisations of all sizes. A common factor was that all had received fit notes with suggested adjustments.

For some, the positive effect was a reduction in sickness absence through a more rapid return to work. This was attributed to various ways in which the fit note worked. One way in which it was seen to do this was by increasing the likelihood of adjustments. For example, a medium-sized hotel, which had received three fit notes suggesting adjustments, said,

‘Wedidn’tpreviouslymakeadjustments.They[employees]justsaid,“weareoffsicksowecan’treturntowork”.I’vegotthedoctor’snote[fit note]sothat’swhyIamsayingithelpsalotmorenowandIwouldliketoseemorepeoplehavingcomebackwithadjustments.’


Rather than empowering the employer, another perceived way the fit note speeded return to work was by empowering the employee. For example, a medium-sized charitable organisation, which had not previously made adjustments, said:

‘IwouldsaythefitnotedefinitelyhelpsbecauseasIseeitisbasically,it’scomingfromyourdoctorandit’sadoctor’srecommendationsoIthink,otherwisepeoplemightfeelabitmorereluctanttoaskforreducedhoursorachangeintheirworkpatterns.’

A belief that the fit note was making employees think more about returning to work was also seen as a way that the fit note was believed to have reduced sickness absence.

Other perceived ways the fit note drove earlier returns to work was by increasing flexibility over adjustments, even where adjustments had previously been made and that the fit note provided more information to aid discussions than the sick note.

Some thought that the fit note had affected sickness absence levels through the organisation making more adjustments and thus reducing relapse.

The description of the effect of fit notes on adjustments was sometimes fairly grudging:

‘IsupposetheonlydifferenceisthatiftheGPisindicatingthatthereneedstobesomesortofadjustmentforaperiodoftime;thatforcesthatdiscussionwhichwouldn’thavenecessarilyhappenedbefore.That’stheonlydifferencethatIcansee.’

As well as affecting adjustments, the fit note was also seen as facilitating an earlier return to work by being able to specify a date when the employee would be fit. This precluded the need for the employee to be signed off (an issue for some employers because they believed that, otherwise, their employee was not insured. Stating ‘may be fit for work’ was also seen as having a similar benefit.

Another type of benefit, ensuring the employer and employee made the right adjustments and were more confident about their actions, was also identified by employers. For example, a small care provider said

‘Ithinkthereareadvantages,Idon’tthinkit’smadeadramaticdifference,Istillthinkinpeople’sheadsthey’resicknotesandthat’sit.ButIthinkthereareadvantagesforemployeeswhogenuinelyhavegotsomethingwrongthatneedstobetakenintoconsideration.It’sformalisedthatprocess.Isupposeinthepastthoseemployeesprobablywouldhavejustcomeinandsaid“ohwellI’vebrokenmytoebutit’salrightI’llcarryonworking”.Andasanemployeryou’dhavethought“wellitcan’tbethatbadbecauseyou’rehere”andyoujustcrackonandyoujustcarryongettingonwithyourjobandtheydoeverythingthattheyusedtodo.Atleastthisway,asanemployeeyoucouldpossiblythinkwellifIgoandseethedoctorandtalktohimhe’llmaybesuggestthingsthatIshouldn’tbedoingthatIcanthenofficiallytaketomyemployerandsayIwanttoworkbutIcan’tdothisandthisoutofmyjobforthenextsevento14daysbecausethedoctorsaysI’mnotallowed.AndIthinkthathasadvantagesforboththeemployerandtheemployee.’

Finally, it was felt that the introduction of the fit note had led to a reduction in sickness absence through prompting employers to change their sickness absence policies.

ReasonsemployersbelievedthefitnotehadnothadapositiveimpactSome employers thought that the fit note had made no difference. There were a number of reasons they gave why they believed this.


The first was the belief that the fit note was unnecessary, which had various sources. Some employers said they made adjustments anyway and the fit note had made no difference to this. This was given as a reason by small, as well as medium and large employers, not all of which had occupational health support. Employers also felt they had their own ways to tackle sickness absence and the fit note was not needed. In addition, employees were seen as keen to get back to work as quickly as possible and did not need the fit note to help them see how to do this.

A second set of reasons employers gave for the fit note having no impact were problems related to the fit notes they had received:

• some employers, who had received no fit notes which suggested any changes, felt the fit note was no different to the sick note and thought that GPs treated it as a sick note;

• the information provided on the fit note when an employee was categorised as ‘may be fit for work’ was not useful. This might be because the adjustments suggested were seen as inappropriate; or no information was provided other than boxes ticked; or that it was seen as poorly completed with parts missing:

‘…there’snotenoughinformationonthefitnote.Whenwebringsomebodybacktoworkwithrestrictionswewanttoknowexactlywhattheycandosothatwefeelsafegivingthemjobs.’;

• employees they deemed fit to work with adjustments were given fit notes stating ‘not fit for work’.

The perceived lack of adequacy of the fit note was attributed by some employers to GPs not understanding the workplace or to the fit note being based on discussions between employees and GPs and so presenting what the employee wanted (in terms of changes or being classified ‘not fit for work’).

A third set of reasons employers gave for the fit note having no impact were problems related to the organisation’s management of the fit notes:

• employees did not co-operate with adjustments;

• managers treated it as a sick note.

In some cases, employers’ observations went further than identifying a lack of positive impact, as there was a feeling that the fit note resulted in additional management demands by raising employee expectations of inappropriate or unfeasible changes.

However, some employers’ comments about the lack of positive effects from the fit note did not correspond with the detailed descriptions they had given of how the fit note had been used in their organisation. For example, one employer who said the fit note was no different from the sick note and that none of the fit notes they had received suggested adjustments, described a fit note which had suggested the employee on sickness absence for stress should speak to human resources and this had resulted in changes for that person in their treatment at work.

Employers with negative views of the effectiveness of the fit note did not necessarily reject the fit note wholesale. Instead, some continued to consider it as a good idea and that it could be valuable if the operation were improved. For example:

‘Thefitnoteisfine,it’stheGPsnotusingitproperly.Thisabsolutelycouldaidusinthatandhelpus,itcould.Butitisn’t,becauseitisnotfilledinproperlyandgiveswronginformation.’


‘ThephilosophyIthinkisagoodone,i.e.repositioningthewholesicknotecultureintohowcanwegetpeoplebacktowork?Andthat’snotwithstandingthisprocessthatiswhatwetryanddofromagoodemploymentpractice,someone’soffsick,ourapproachis“okaysomeone’soffsick,howarewegoingtotryandgetthembacktowork?”Andthereforepotentiallythiscouldbeareallygoodandhelpfulprocess,butthere’stwothingsthathavegottohappen.One,GPshavegottobebraverandchallengetheirpatientsinsaying“well,howcanIgetyoubacktowork”,whatcanyouremployerdo,andmakethosejudgementcalls,andthat’stheirmindset,theirtraining,theireducation.Andthenwhentheyaremakingthoserecommendationstomakethemclearer.SoasIsay,philosophicallyI’mabsolutelyinagreementthatthisistherightapproach,butiftheprocessisnotbeingexecutedintheappropriateway,thenthere’sgoingtobenodifference.’

On the other hand, some were entirely negative:

‘It’sacompletewasteoftimeandifyouwanted,Ithinkitshouldbeabolished,Ithinkitis,we’vegottosay,itisuseless.Wewillfindoutwhatiswrongourselves-andwhatGPswritecannotalwaysbetrusted.’

9.1.2 Views on the effect of the fit note on the management of sickness absence

Some employers thought that the fit note affected their ability to manage sickness absence. For some this was positive, with the fit note prompting changes in policy resulting in better management of sickness absence:

• Managers or employees being better informed on appropriate action, reducing work for managers

‘Weusedtheintroductionofthefitnoteasanopportunitytoimproveourabsencepolicies,includinggettingACASintodoatwo-hoursessiontostaff.’

‘Itreinforcedwhatweweredoinganyway.Ithinkthat’sgood,andIthinkthey’rerightthatthey’reputtingadate,andIwon’tneedtoseeyouagain,soIknow,forafact,Icantakeitfromthatdate(withouthavingtobesignedoff).’

‘Wedidreducethesizeofouroccupationalhealthfunction,wehavescaledthatback.Nowwedidn’tdothatasaresultofthefitnote,weweredoingitbecausewehadtodoit.Butinmyownmind,Ihavelittledoubtthatwe’vebeenassistedinthatbytheintroductionofthefitnotebecauseithastakensomeofthatonusofresponsibilityofftheoccupationalhealthprofessionalstomakethosedecisionsbecauseGPsandlinemanagersareabletoalmostcutthemoutasthemiddleman.’

Some were still in the process of making management changes in response to the fit note. For example, a large organisation was about to change their human resource system to record the fit note details:

‘Thenwe’llbeabletoreportbetteronhowmanyarewegettingthroughthatareactuallyaboutadjustments,whatarethetypesofadjustmentstheGPsaresuggestingandwe’llbeabletodoabitmoreonthat.Wedidn’tdothechangesbeforenowbecauseforthelastfouryearswe’vebeenonthevergeofchangingtheHRsystemandit’sacaseofdoyouwait,doyoudoit,doyouwait,doyoudoit.It’sjustgotothestageof:doit.’


For some, the fit note was seen as making sickness absence management more difficult through:

• having to manage adjustments;

• having to deal with proposals on the fit note which were seen as inappropriate;

• having to deal with fit notes which were incomplete, contradictory (e.g. stating both ‘not fit for work’ and ‘may be fit for work’);

• having to manage raised employee expectations about adjustments;

• reducing, in the employers’ view, their control, due to a belief that they were required to make the adjustments detailed in the fit note;

• lack of clarity of GPs statements meaning that more cases had to be referred to occupational health.

Increased management difficulties were sometimes due to an employers direct response to the fit note, for example, only making the changes suggested on the fit note, instead of making adjustments (as previously) as the employer thought fit.

For some employers the fit note’s effect on management was seen as resulting in a one-off management cost, merely updating the wording of their policies (such as changing references to ‘sick note’ to ‘fit note’).

None seemed to think that the fit note had altered which health conditions were easier or more difficult to manage.

9.1.3 Employers’ views on other impacts of the fit noteEmployers were also asked about whether they thought the fit note had affected attitudes about sickness absence or information flows from GPs. Some felt that the fit note had had no effect on these factors. However, some did feel the fit note had had some impact on these factors. One saw it as affecting line managers’ attitudes:

‘Ithinkwe’rebeginningtoseeabitofaculturalchangeintermsofsomethingthatwe’vebeentryingforalongtime,ofgettinglinemanagerstotakeaccountabilityformanagingabsenceandtalkingtopeopleabouttheirreturnstowork.Ithinkthefitnotehasassistedthatculturalchangein...givingthemabitofreassurancethat[they]havegotsomethingtobasethisdiscussiononsotheyperhapsfeelmoreconfidentabouthavingthosediscussions.’

Some employers believed the fit note had affected employees’ attitudes, making employees think more about returning to work. However, the change in employees’ attitudes was also sometimes seen as a problem, with raised expectations about adjustments.

Information flows with GPs were believed to have improved where employers had had fit notes which they felt contained useful information. One aspect of improved information was the fit note stating whether the doctor would need to see the employee again.

Another example of improved information flows was where the employer checked with the doctor that the adjustments they proposed were appropriate. This was done either directly, through writing to the doctor or indirectly, through discussion with the patient and getting them to check with their doctor. Other examples were where the fit note was incomplete (for example, not stating whether ‘not fit for work’ or ‘may be fit for work’ or suggesting a phased return, but not providing any dates) and the employer had sent the fit note back to the GP and received it back completed.

At the same time, others reported that doctors would not communicate with them.


9.2 Suggestions for improvement to the fit noteEmployers were asked for their suggestions for improving the fit note. Many suggestions were obvious responses given the problems of the fit note that the employers had identified (for example, that doctors should complete the fit note fully) described in detail in earlier chapters. Here, we provide a brief overview of employers’ suggestions for improving the effectiveness of the fit note, focusing on suggestions not discussed elsewhere.

9.2.1 Improvement in GP/employer relationsOne of the main areas suggested for improvement was GP/employer relations. Some large employers had instigated activities to educate GPs better about the jobs and workplace demands, so the GPs might be better able to complete the fit note. One example was an employer sending information to local GPs. Another was inviting GPs to tour the workplace. These and other employers felt that more general contact between employers and GPs, for example, seminars and discussions, workplace tours and written information, would be useful. For the individual employer this was only viable where the employer was large and dealt with relatively few GPs (for example, its employees’ homes were concentrated geographically). However, joint employer action was seen as potentially effective, although there was some uncertainty over whether GPs would have the time to participate. An indirect effect of this approach was also thought to be the potential for greater direct exchange of information on the appropriateness and detail of adjustments in specific cases.

9.2.2 Varying views on the level of information that should be provided on the fit note

The theme of doctors’ job and workplace knowledge was also taken up in suggestions about what information the fit note should contain. Some felt that doctors should be less prescriptive and provide more information on capabilities, leaving the employer to work out potential adjustments. This was both because these employers felt that they were best placed to consider adjustments and that this approach would not lead employees to have inappropriate expectations. However, this preference was not universally held, with some employers preferring details of adjustments. One suggestion was that the fit note should contain the suggestion that the employee should talk to their employer about adjustments without suggesting what these adjustments should be and that the doctor should also suggest this.

9.2.3 Training on the fit note should be provided to GPsA related suggestion was that doctors should be provided with training on the fit note and the questions to ask employees. Access to further training on the fit note was also something that was raised by GPs themselves in a recent qualitative study (see Fylan etal., 2011). GPs indicated their belief that take-up of any such training for GPs would be higher if it was framed in the context of preventing long-term sickness absence rather than guidance on form filling (Fylan etal., 2011).

9.2.4 Varying views on the number of tick boxes on the fit noteSome employers felt that more tick boxes (on capabilities or adjustments) would encourage doctors to provide more information, although others thought the diversity of jobs in the labour force meant that the number of boxes required precluded this approach.


9.2.5 An occupational health adviser could act as a helpful liaison between employers and GPs

Because doctors were not specialists on the workplace and adjustments and employers were not experts on illness and capabilities, some employers suggested that, for those without occupational health (and similar) specialists, some form of occupational health advice and support between the employer and doctor would be useful. This seemed most needed by smaller organisations, where occupational health expertise was viewed as too costly.

Other suggestions to help employers to manage sickness absence included:

• the fit note being provided after three days, which was closer to assisting the concerns of employers who focused on short-term absence;

• adding a fit for work box and a space to state when the person would be fit.

63Discussion and conclusions

10 Discussion and conclusionsKey points• The evidence suggests that the fit note is likely to have reduced sickness absence by

facilitating return to work.

• The fit note is likely to have had more effect in smaller organisations; organisations where adjustments were not previously made; organisations without previous formal employer/employee discussion procedures on sickness absence; and organisations without occupational health or other specialist health resources.

• The fit note appeared to have led to adjustments, improved sickness absence processes and empowered employees to seek adjustments. However, the research identified a need for improvements in some employers’ approaches.

• The effectiveness of the fit note in addressing the policy objectives might be improved by measures to increase use of the ‘may be fit for work’ option; improve the detailed information provided on the fit note and, perhaps, its design; increase dialogue between GPs and employers.

• It may be useful to consider ways to provide better protection for employees to avoid returns to work that could be harmful because they are premature, too rapid or not supported with appropriate adjustments.

The study has explored how the fit note was used by employers and employees. It has examined a range of types of organisations, with differing absence management approaches and concerns, for employees with a range of conditions. In this chapter the findings are brought together to consider the effect of the fit note, issues raised by its operation and how its effectiveness might be improved. The study also examined employers’ sickness absence approaches. Key points from these with relevance to the fit note and sickness absence in general are also discussed.

10.1 The effect of the fit noteThe influence of the fit note on the extent of sickness absence has operated through various mechanisms. The fit note can influence sickness absences by:

• prompting employers to consider, discuss and make adjustments to assist return to work;

• prompting employers to change their sickness absence processes, including introducing formal discussions about return and adjustments; and, where formal discussions already took place, changing who was involved or when these occurred;

• empowering employees to seek adjustments; and

• leading to the (erroneous) belief that employers must follow the advice given on the fit note.

Detailed evidence of the use of the fit note suggests that its influence on management of sickness absence is likely to have had a positive effect on sickness absence durations.

It has led to greater consideration of whether an employee might return to work before having fully recovered and to greater use of adjustments to enable return. Thus, some employees have returned to work more quickly. For some employees, it has eased their return to work, enabling a gradual

64 Discussion and conclusions

build up to normal duties or to permanent changes to improve their work experience. The latter may even continue once fully fit. Easing the return through phasing and adjustments should reduce relapse and subsequent sickness absence.

However, the fit note has resulted in some employees returning before they are fit enough and agreed adjustments are not always made, which can cause employees difficulties, including pain and stress, delayed recovery and exacerbation of health conditions. For these employees, sickness absence may be reduced through earlier returns to work, but productivity will not always increase proportionately and further sickness absence, due to relapse, is a risk.

Whilst it is clear that the fit note has reduced time off initially, it is not possible in a study of this kind to be certain whether this is counterbalanced by relapse and so whether, overall, the fit note has reduced sickness absence. However, it seems likely that it will have done.

The effect of the fit note has varied between organisations. It appeared to have had greater influence in organisations which:

• had not previously considered or made adjustments;

• did not have formal systems for discussions with absent, sick employees and on return from sickness absence; and

• did not have occupational health and other specialist healthcare professional resources.

These characteristics are more common in smaller organisations and so, in spite of adjustments being more difficult in smaller organisations, it seems likely that the effect of the fit note has been greater in such organisations.

The variation in effect by characteristics partly explains why some employers considered the fit note to have been ineffectual, as some were already taking the actions the fit note sought to encourage.

10.2 Strengths and limitations of the researchThe major strength of the research is that it explores the experiences and perceptions of a wide range of employers and employees. The sampling structure ensured that the participating organisations were of varying size and from differing industries and sectors. The £100 incentive for employers and £25 incentive for employees also ensured that the achieved sample did not comprise only of those individuals with strong opinions about the fit note. As the research is qualitative, we do not know the extent to which we can generalise the findings. However, the themes and issues raised by employers and employees are likely to be similar to those shared by others.

10.3 Implications for policy and practiceWhilst the evidence suggested that the fit note is likely to have reduced sickness absence, it also identified issues which might hamper its effectiveness. The findings also pointed to wider issues for the Department for Work and Pensions (DWP). These are all discussed below.

The issues relating to the fit note are of two types: fit note policies and practices (for example, design of the form, procedures and support for its use) and employers’ policies and practices. DWP has greater control over the former. It needs to take the latter into account when considering changes to fit note policy, but may also be able to influence employers’ policies and practices.


10.3.1 Fit note policy and practice The study raises a number of issues about the way in which the fit note is used, specifically, its content, GP’s use of the ‘may be fit for work’ option, the need for employer education and support and the protection of employees’ health. These are discussed below.

FitnotecontentEmployers had a range of criticisms of the fit note’s content and the quality of its completion, indicating that completed information could be inadequate, erroneous and confusing, particularly:

• date information, for example, what dates mean or what dates relate to (being ‘not fit’, ‘may be fit’ or ‘fit’, or period of adjustments) dates being omitted;

• uncertainty over use of the term ‘phased return’, which seemed to be interpreted in different ways (often, but not always being interpreted as adjusted hours, rather than phasing of changes) which may cause confusion between employers, employees and GPs and result in inappropriate changes (or lack of changes);

• omission of information on whether the doctor needs to see the employee again or not; and

• too little information, in general provided by GPs when completing fit notes, for example in the space for comments.

These issues were highlighted by all types of employers and it seemed that there was a need for more careful and detailed completion of the fit note. As such, the design of the fit note, and guidance about its completion might be reviewed to improve completion and reduce confusion:

• ‘phased return’ is listed together with amended duties, workplace adaptations and altered hours as if it is an adjustment in itself rather than a process for the other adjustments; it may be helpful if the fit note made this clearer;

• a clearer system for recording dates so that these are both recorded by GPs and give the period of fitness or unfitness for work and of adjustments;

• the need to assess fitness for work again seemed often to not be completed; this may be due to the layout making it easily overlooked.

In relation to lack of information employers varied in exactly what information they wished to see on the fit note about the employees’ health condition, capabilities, limitations and any workplace adjustments. Some, particularly those with recourse to occupational health and other health specialists, wanted the diagnosis together with indications of capability as they felt they could then make their own judgements about suitable adjustments. Others, particularly employers who had fewer resources at their disposal for managing absence, seemed to want very detailed information regarding what the employee could and could not do which was relevant to their job, including how this should be phased (such as the weight of objects they could lift and how this should be gradually increased). However, information this detailed was not wanted by employers who felt able to form their own judgements, as it was seen as making managing employee expectations more difficult. In both cases, greater indications of time periods of limitations were wanted.

These conflicting needs present difficulties for improving the operation of the fit note. One approach would be to try to get doctors to tailor the fit note to the employer (as well as the employee). Identifying whether the patient could see an occupational health specialist at work would be a useful approach, with information then tailored to the specialist. Where occupational health specialists are unavailable, employer size may be a useful indicator of the detail of information required. At the same time, given the constraints of GP-patient consultation lengths, it is not


practical for the onus for improved communication to rest solely with doctors. Other ways to improve communication and understanding are discussed below.

A further issue raised by employers was that it would be useful for the fit note to include a ‘fit for work’ option (or provide a date when the person should be regarded fit for work). Given the statement about whether the person needed to be seen again, this may already be implicit on the fit note, but perhaps points to a need for doctors to complete this section more often, and for employer education on what the guidance provided in the various parts of the fit note means.

GPs’useof‘maybefitforwork’There are some indications from employers and employees that GPs may be reluctant to use the ‘may be fit for work’ option. Sometimes employees classified as not fit for work returned to work without reported problems and some employers considered that sometimes employees were classified as such when adjustments were possible. Similarly, some employees described difficulties getting doctors to understand that they might be fit for adjusted activities. This may be for a range of reasons, including good judgement of the patients’ best interests, concern about how the employer will respond, lack of understanding of the work possibilities and benefits of a more rapid return or, simply, over-cautiousness. It would be useful to understand this better to see whether more people could be classified as ‘may be fit for work’ and be returned to work successfully earlier.

EmployereducationandsupportThe research findings suggest a need for education and support by some employers to enable them to use the fit note more effectively. There were indications that effective use of the fit note was hindered by several factors including lack of knowledge on how to make adaptations, lack of knowledge on conditions and how employees’ support needs may vary according to these and other factors, lack of processes to facilitate return to work particularly discussions with employees, and belief that the fit note is prescriptive rather than advisery. There was a tendency to use reduced hours, rather than other options, which were, perhaps wrongly, viewed as either more costly or difficult. It is likely that these challenges with responding to the advice provided on fit notes are greatest amongst small and medium-sized employers.

There appears to be a need for further to educate some employers about the role of the fit note which provides guidance on how they can use it most effectively. This includes guidance and advice for employers on good practice in managing sickness absence in general, and more specific guidance on how to make adjustments for different types of health condition and occupations might be provided. This would be most beneficial for organisations without access to occupational health and other specialists. In addition, support for employers to implement aids to make adaptation, greater awareness of Government support available through the Access to Work scheme might also help employers to use the fit note more effectively.

In order to improve practice, managers at all levels, including line managers and human resource specialists, need training in the use of the fit note. Line manger training is particularly important, given that decisions about adjustments are often taken by individuals in this role.

GP/employerliaisonA number of the issues raised suggest a need for better understanding and dialogue between doctors and employers, and ways of encouraging this could be considered.


Protectionofemployees’healthThe research has identified concerns that employees sometimes return to work in the expectation of adaptations which are then not implemented. This places employees who believe they can return to work in a difficult position, and one which is potentially exacerbated by certain absence trigger systems. While an employee has the option of returning to their doctor to ask to be signed off as not fit for work, it was clear that some did not take this option and continued to work without adjustments. It might be useful to consider whether it is necessary to provide better protection for employees whose employers do not make the adjustments suggested and how this might be achieved.

10.3.2 Employers’ approaches, policies and practices and the fit note Employers’ (along with GPs’) policies and practices, explored in this study, set the context within which the fit note operates. Many policies and practices influenced the use and effectiveness of the fit note directly. These include the use of occupational health specialists, reporting and management procedures for sickness absence and the use of return to work interviews. Other policies and practices may have an important indirect influence on the effectiveness of the fit note, in particular in relation to sickness absence policies. In this final section of the report, we consider changes in practice in sickness absence management that might enhance effective use of the fit note. The evidence points towards the need for employer flexibility in managing returns to work, as well as the use of resources and knowledge of appropriate adjustments in individual cases.

This may be of particular interest to employers, employer stakeholders and policy makers in the field of employment and health.

Employers’returntoworkprocessesThe fit note appeared to work better to facilitate return to work where the following sickness absence processes were in place:

• discussion with employees of the fit note and adjustments (e.g. in return to work interviews); holding such discussions at an early stage may be particularly beneficial;

• development of a detailed plan for return, including details of phasing;

• monitoring how well the return to work plan works; and

• allowing flexibility in the implementation of the plan and responding to changes as necessary.

More active encouragement of employers to use the above processes might improve the response to the fit note and its effectiveness. In addition, the involvement of occupational health after relatively short-term sickness absence varied and it might be helpful if employers with these resources were encouraged to use them more widely.

MonitoringsystemsformanagingsicknessabsenceAs explained in Chapter 2, some employers deploy trigger systems for managing sickness absence (including using Bradford scores), in which the number of days or pattern of absence prompts action on absence. Some employers use these systems fairly rigidly with little consideration of the circumstances resulting in absence, whereas others are more flexible. Trigger systems which are rigid and place more weight on the number, rather than the total length, of absences work counter to the fit note approach, discouraging employees from returning until they are fully fit, in case this leads to a need for a second period of absence. There was also evidence that rigid use of trigger points could have an impact on morale of the employees reaching trigger points and on


their colleagues. A more flexible approach to trigger systems which allows consideration of the circumstances of absence was favoured by some employers, although it required more sophisticated management. To improve the effectiveness of the fit note, it might be useful for some employers to take a more flexible approach to triggers.

FinancialincentivestoreturntoworkThe effectiveness and consequences of the fit note for employers and employees varies across organisations depending on sick pay provisions and on pay arrangements for reduced hours or adjusted tasks on return to work. Incentives to employers and employees to make adjustments to facilitate an earlier return depend on the relative costs of absence and also the costs of working with adjustments, for each party. Incentives are affected by the use of trigger systems (discussed above), pay when on reduced or amended duties, whether there is occupational sick pay (OSP) and long-term effects on career and pay.

In respect of adjustments involving phased returns, amended duties or altered hours, some employers paid employees their normal pay, but others changed pay with the duties and hours. This provides different incentives for employers and employees to seek a return with adjustments. The strength of incentives also depends on whether there is OSP.

For employees, longer-term financial considerations may also provide an incentive to return with adjustments, if sickness absence is considered to affect pay progression, career and employment prospects. Within the study, only the latter consideration was raised, with some employees concerned about the effect of sickness absence on selection for redundancy.

69Appendices – A sample copy of the fit note

Appendix A A sample copy of the fit note

70 Appendices – Method

Appendix B MethodB.1 Introduction The research was based on qualitative research with 54 employing organisations.

The aims of the interviews were to provide an understanding of the range of processes involved in dealing with and responding to the fit note; general sickness absence policies and practices; the process of the fit note, including who is involved; and the facilitators and barriers to responding to the fit note. The interviews also explored how health and human resources specialists, line managers and employees are involved and respond to the fit note. Linked employer-employee information also ensured that the study examined both policy and practice.

Initially, the research was in two discrete strands: case studies (comprising more than one interview with managers/absence specialists) and other qualitative research (comprising a single interview with managers/absence specialists). Both strands were to identify policy and employers’ experience of the fit note through interviews with the person with an overview of sickness absence management in the organisation. Both were to seek interviews with employees to identify their experience of the fit note. However, through multiple employer interviews (and, particularly through including interviews with line managers), the case studies were expected to provide more robust and detailed information on practice. At the same time, respondents in the qualitative research were encouraged to include line managers and occupational health specialists in the single employer interview, to gain this wider perspective. Discussion guides, tailored to the type of respondent, were the same for both strands. The case studies and other qualitative research were to be analysed separately, with findings brought together to develop implications and conclusions.

It became clear early in the research that the classification of the fieldwork into case studies and other qualitative research was not useful. In some cases, the ‘person with an overview of sickness absence management’ had the same detailed knowledge of the line manager respondents and, indeed, was also a line manager with experience of the fit note. In other cases, the range of interviewees was the same in the single-interview research as in the case studies. Therefore the distinction was dropped and all material analysed jointly.

B.2 The sample

B.2.1 OrganisationsThe employing organisations were selected purposively to ensure a spread across a range of different characteristics including:

• size: large, medium and small organisations;

• sector: public, private and third sectors;

• single and multi-site;

• location;

71Appendices – Method

• industry: the sample was weighted towards industries with relatively high absence rates or with occupations with relatively high absence rates as well as industries with a concentration of low paid employees given the DWP’s interest in these areas.

Initially, sampling matrices for organisation size and sector were drawn up for case studies and for the other qualitative research separately, Table B. 1 and Table B. 2. These were not amended when the distinction between case studies and other qualitative research was dropped and the matrices continued to provide a guide to sample selection.

Table B.1 Initial sampling matrix for case studies: number of organisations to be sampled

Number of employeesSector 1-49 50-249 250-999 1,000+ TotalPrivate 1+ 1+ 1+ 1+ 4-5Public 1 1 1 2-3Voluntary 1Total 1-2 2-3 2-3 2-3 8

Table B.2 Initial sampling matrix for other qualitative research: number of organisations to be sampled

Number of employeesSector 1-49 50-249 250-999 1,000+ TotalPrivate 5+ 5+ 5+ 5+ 20-30Public 3+ 5+ 15-20Voluntary 5-10Total 10-12 20-23 8-10 8-10 50

The sample was to cover a range of industries and occupations, including, for the case studies, social care (public sector), food processing and call centres whilst the other qualitative research was to include health and education.

All organisations were to have received a fit note and at least one third were to have had fit notes which had suggested adjustments.

Potential participant organisations in the private sector were identified using a commercial database and, in the public and voluntary sectors, using internet searches.

B.2.2 Sampling employeesOur intention was to select employees to ensure that we covered a range of characteristics including:

• nature of the illness;

• occupation (especially manual/non-manual, managerial/non-managerial);

• gender;

• age;

• whether returned to work.


However, a low opt-in rate from employees meant that we interviewed those employees who agreed to take part in the study.

B.2.3 The achieved sampleFifty-four organisations participated in the study. Their characteristics are described in Table B. 3, which shows a wide spread across industries. Owing to difficulties identifying smaller organisations which had had a fit note, the sample had slightly more larger organisations than initially planned.

Table B.3 Characteristics of participating organisations

Number of employees

Industry 1 to 50 51 to 250251 to 1,000

1,001 to 5,000 5,001+ Total

Manufacturing 2 1 3Food processing 1 2 3Other non-services 1 1 1 3Retail 2 2Hotel 1 1 2Entertainment and leisure 2 1 1 4Banking and Insurance 1 1Professional and business services 2 1 2 1 6Charity 1 2 2 2 7Public administration 3 1 4 8Emergency services 1 2 1 4Health 1 1Education 2 1 1 4Social care 3 1 4Other services 1 1 2Total 6 16 15 10 7 54

Within these organisations 185 people were interviewed: 98 managers and specialists and 87 employees who had had a fit note, Table B. 4. Multiple manager/specialist interviews were conducted in 19 organisations (rather than eight as originally planned). Employees were interviewed in 26 organisations.

73Appendices – Method

Table B. 4 Job characteristics of interview participants

Multiple employer representatives interviewed Total

Single employer representative

interviewed Specialists onlySpecialists and

ManagersNumber of organisations 35 8 11 54

Number of people interviewedEmployer representatives 35 46 17 98 Specialists Human resource 23 21 16 60 Occupational health 1 4 0 5 Health and Safety 1 0 1 2 Managers Line managers 0 18 0 18 Senior managers1 10 3 0 13Employees 44 17 26 87

1 For example, Managing Director, General Manager.

Interviews were conducted with the person responsible for absence management and, where possible, with a line manager from the organisation. We aimed to include at least eight organisations in which at least one line manager was interviewed as well as the person responsible for absence management. In the remaining 48 interviews, the person(s) responsible for absence management were interviewed.

B.3 FieldworkInterviews were conducted by NIESR employment researchers. With the agreement of the interviewee, interviews were recorded. Otherwise, notes were taken by the researcher.

Fieldwork was conducted between March and July 2011.

B.3.1 Interviews with employersInterviews with the person responsible for absence management were mostly conducted face-to-face. However, in a few cases interviews were conducted over the phone. Each interview lasted for approximately an hour.

Interviewers used a semi-structured discussion guide and covered the following topics:

• general background of the organisation;

• sickness absence in the organisation;

• absence management approaches;

• preparation for the fit note;

• fit note: numbers and processes;

• the fit note content;

• discussions with employees;


• assistance back to work/adaptations;

• effects and assessment of the fit note.

Interviews with line managers tended to be conducted over the phone, although a few of these interviews were conducted face-to-face. Each interview lasted for approximately 30 minutes.


• background information on the line manager;

• sickness absence amongst their staff;

• absence management approaches;

• preparation for the fit note;

• fit note experience;

• the fit note content;

• assistance back to work/adaptations;

• effects and assessment of the fit note;

• other considerations.

B.3.2 Interviews with employeesInterviews with employees were either conducted over the phone or face-to-face depending on the preferences of the employer and the availability of the employee. The duration of each employee interview was approximately 30 minutes.


• background details;

• absence management policy and procedures;

• experience of the fit note focusing on any changes that were recommended on the fit note to facilitate an early return to work;

• return to work;

• other factors.

Interviewers gained the informed consent of all interviewees prior to conducting the interview. All interviews were recorded, transcribed and then analysed thematically taking information from all types of interviews into account where relevant.

B.4 AnalysisRecordings were transcribed. Where interviews were not recorded, a note was written up after the interview.

Analysis was thematic, with themes drawn up from the main issues of prior interest and issues which appeared to be important from discussion by the researchers of the interviews. All interviews were analysed together (i.e. managers, specialists and employees), except where questions were asked of selected groups only (e.g. employees’ experience of the GP consultation; and sickness absence rates).

Published by the Department for Work and PensionsApril 2012www.dwp.gov.ukResearch report no. 797 ISBN 978-1-908523-59-4

This report forms part of a programme of evaluation to gather evidence on the use of the Statement of Fitness for Work (fit note). On 6 April 2010 the Government implemented the fit note across Great Britain to help people who are off sick get back to work as quickly possible.

The study was based on qualitative research with a purposive sample of 54 employing organisations that had some experience of using the fit note. It explores the experiences and outcomes of the fit note from the perspectives of employers and employees to understand how these differ across businesses or organisations. The study involved interviews with employer representatives and employees conducted between March and July 2011.

If you would like to know more about DWP research, please contact: Carol Beattie, Central Analysis Division, Department for Work and Pensions, Upper Ground Floor, Steel City House, West Street, Sheffield, S1 2GQ.http://research.dwp.gov.uk/asd/asd5/rrs-index.asp

Documents

Evaluation of the Statement of Fitness for Work: qualitative … · 2013. 7. 16. · They include the 98 anonymous employers across 54 organisations and the 87 . employees across